Module 37: Look-Alike / Sound-Alike (LASA) & High-Alert Drug Safety
Practical, visual, and procedural strategies to prevent catastrophic mix-ups.
From Confusion to Clarity
In your pharmacy career, you’ve been trained to be vigilant about look-alike/sound-alike drugs. You know the classic pairs: hydroxyzine and hydralazine, Adderall and Inderal. In the hospital, this foundational knowledge is stretched to its limit. The sheer number of injectable medications, the similarity in packaging and labeling from manufacturers, and the fast-paced, high-stress environment create a perfect storm for potentially fatal medication errors.
This module elevates the concept of LASA from a simple memory exercise to a systematic, environmental, and procedural science. We will move beyond just recognizing confusing drug names and dive into the practical, real-world strategies that hospitals implement to build layers of safety into the medication-use process. You will learn to see the pharmacy and the nursing unit through the lens of human factors engineering, identifying risks in storage, labeling, and technology that can lead to catastrophic mix-ups.
This is the retail shelf look-alike problem—except every error here goes straight into a vein. This module provides the street-smart survival guide to ensure you are a proactive force for safety, capable of identifying and mitigating these critical risks before they can ever reach a patient.
Module Outline: A Systematic Approach to Medication Safety
We will build your expertise layer by layer, from identification of risks to the implementation of robust, system-wide prevention strategies.
Identifying LASA Pairs and Packaging Hazards
Learn to see your pharmacy’s inventory with new eyes. We’ll explore the most common and dangerous LASA pairs in the hospital setting and analyze how manufacturer packaging creates hidden traps for the unwary.
Labeling, Storage, and ADC Configuration Strategies
Discover the practical tools of error prevention. This section covers the use of warning labels, strategic segregation of high-risk drugs in the pharmacy and ADCs, and configuring technology to build safety nets.
The “Tall-Man Lettering” System Explained
A deep dive into the science and application of one of the most effective visual safeguards. We’ll review the ISMP-recommended list and discuss how to apply it consistently in labeling and electronic systems.
High-Alert Drugs: Double-Check and Independent Verification Procedures
Mastering the human-based safety systems for the most dangerous medications. This section covers the definition of a true independent double-check and its critical role in preventing errors with drugs like insulin, heparin, and narcotics.
Real Case Studies: Near Misses, Root Causes, and Prevention Protocols
Learn from the mistakes of the past. We will analyze real-world medication errors involving LASA and high-alert drugs, perform a root cause analysis, and discuss the specific prevention strategies that could have broken the chain of error.