3.1 High-alert/risk medications and look-alike/sound-alike (LASA) medications

What does LASA stand for?

Look Alike Sound Alike

What is tall-man lettering?

A safety practice that uses mixed-case capitalization (e.g., predniSONE vs. predniSOLONE) to highlight the differences in look-alike or sound-alike (LASA) drug names

What are three examples of LASA drug similarity?

Generic-generic similarity, brand-brand similarity, and generic-brand similarity

What are some examples of similarities that amplify LASA risk?

Similar strengths, and pills that look the same in the amber bottle

What is the LASA safety strategy: Physical Separation?

Separate LASA pairs physically. Store in different locations or shelves to prevent mix-ups.

What is the LASA safety strategy: Tall Man Lettering?

Apply tall-man lettering to distinguish look-alike names

What is the LASA safety strategy: Color Coding?

Use color-coded caps and place warning stickers on bins and e-pick shelves

What should be done after a LASA error occurs?

Report the error, document details, notify pharmacist, implement prevention strategies

What are the ISMP high-alert medications?

Insulin, Anticoagulants, IV Chemotherapy, Neuromuscular Blockers, Inotropes, Narcotic Concentrates

What defines a high-alert medication?

Drugs that have a high risk of causing significant patient harm if used incorrectly

Why is insulin considered high-alert?

Small dosing errors can cause severe hypoglycemia or death

What is the major dosing trap with methotrexate?

It is usually taken weekly, not daily. Daily dosing can be fatal

Why is IV potassium dangerous?

Can cause fatal cardiac arrythmias if given too fast or in high doses

Why are trailing zeroes prohibited? (Ex. 5.0mg)

Can be misread as 50mg

Why must leading zeroes be used? (Ex. 0.5mg)

Prevents misreading as 5mg

What is the purpose of barcoding scanning in medication safety?

Ensures the right patient, drug, dose, route, and time

What is a DUR alert?

A system warning for drug interactions, allergies, or incorrect dosing?

What is an example of a soft DUR alert?

Therapeutic duplication

What happens with a soft DUR alert?

Requires pharmacist review and counseling

What is an example of a hard DUR alert?

Drug-Drug Interaction

What happens with a hard DUR alert?

Requires immediate intervention, hold and consult prescriber

When are independent double checks required?

For high-alert medications like insulin, heparin, and chemo