Running head: LOOK-ALIKE SOUND-ALIKE RELATED MEDICATION ADMINIST 1

Look-Alike Sound-Alike Related Medication Administration Errors

Morgan McMahon

University of South Florida

LOOK-ALIKE SOUND-ALIKE RELATED MEDICATION ADMINIST 2

LASA Related Medication Administration Errors

Medication administration is a vital aspect of patient-centered care that nurses perform on a daily

basis. While the method of administering medication may be simple, the process of obtaining the

medication and giving it to the patient has many different avenues where medication errors can

occur and cause injury or even death to the patient. One common medication administration error

that occurs is caused by medications that sound-alike and/or look-alike (LASA). Due to the

similarity in sound or sight, these medications have an increased chance in resulting in

administration of the wrong drug to the patient.

Medication Error

Medication errors involving LASA drugs account to one in four medication errors in the

United States (Bryan, Aronson, Hacken, Williams, & Jordan, 2015). A LASA drug associated

medication error can occur when the nurse misreads or mishears a providers orders, obtains the

wrong LASA medication from the dispenser, or even confuses two different patients

medications due to the similarities between the sound and spelling. An example of a LASA

medication includes minoxidil (Loniten) and midodrine (ProAmatine). While minoxidil is an

antihypertensive, midodrine treats low blood pressure. If minoxidil is given incorrectly to a

patient that requires midodrine, the patients blood pressure could potentially plummet, making

the patient even more hypotensive and increasing the risk for complications and death (Wollitz &

O'Conner, 2015). LASA associated drug medication errors are at an increased risk for occurring

when the nurse has many distractions throughout the medication administration process (Hayes,

Jackson, Davidson, & Power, 2015). Potential distractions that the nurse could encounter come

from a multitude of different sources including the patient receiving the medication, the nurses
LOOK-ALIKE SOUND-ALIKE RELATED MEDICATION ADMINIST 3

other patients, other health care professionals, colleagues, and family members. Because the

nurse has a large involvement in the direct care of the patient, distractions often occur every shift

(Hayes et al., 2015). The combination of distractions and LASA medications not only increases

the nurses chance of making an error, but also puts the patient at a higher risk for harm.

Nursing Interventions

Due to the high incidence of LASA associated medication errors, there have been

techniques and nursing interventions to ensure that the patient receives the right medication. One

intervention is the application of checking the six rights at three different and specific times

before giving the medication to the patient. The six rights include: right patient, right drug, right

dose, right route, right time, and right documentation. The nurse should check the six rights

when looking at the patients chart, pulling the medication out of the dispenser, and right before

giving the patient the medication in order to ensure patient safety (Hayes et al., 2015). Another

intervention that nurses can use to reduce distractions during medication administration is to

review the providers orders and the patients chart in a quiet space such as the med room. By

focusing and correctly identifying the right patient, medication, route, drug, time in a quiet area,

the nurse has a higher chance of correctly administering the medication and maintaining patient

safety (Grissinger, 2012). Although it is not a nursing intervention, one way that drug labeling

companies are trying to highlight the differences in LASA medications is through tall man

lettering. This technique is a visual aid for nurses to see the difference in look-alike medications

by capitalizing the unique letters of the medication name that is distinct from the look-alike drug

(Lambert, Schroeder, & Galanter, 2015).

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Personal Fear

When thinking about my future as a registered nurse, I am most afraid of the distractions

that nurses face on a daily basis when giving medication. My fear of giving the wrong

medication or wrong dosage is closely related to the amount of distractions that the nurse deals

with everyday, especially from the other patients. As a nurse, I want to care for each individual

equally and provide them with the full care that they deserve. In order to keep my medication

administration without error, I think I will take certain precautions when I am with a patient

giving medications. One of the biggest distractions that I have seen in the hospital is from the

phones that nurses carry with them during the day. When I am a nurse, I want to give my patient

my full attention, and unless there is an urgent situation, I will not answer my phone when

passing medications. I will also close the door and divide the room with the curtain to create a

more private space with the patient in order to decrease the possibility of distractions.

Conclusion

In conclusion, the nurse has an irreplaceable role in patient care, and an essential task that

the nurse completes is medication administration. One of the most significant causes of error

when passing medications involves the use of LASA drugs, and the incidence of errors is greatly

increased when the nurse encounters multiple distractions during the medication administration.

Due to the high occurrence of the LASA related medication errors, nursing interventions such as

identifying the six rights three times before administration, finding a quiet area to review the

medications before administration, and tall- man lettering are used to decrease the number of

medication errors. Nurses carry a large responsibility through giving medication, and their focus

during administration of medications can determine life or death situations for patients.
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References

Bryan, R., Aronson, J. K., ten Hacken, P., Williams, A., & Jordan, S. (2015). Patient safety in

medication nomenclature: orthographic and semantic properties of international

nonproprietary names. PloS one, 10(12), e0145431. Retrieved March 19, 2017, from

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0145431

Grissinger, M. (2012). Physical environments that promote safe medication use. Pharmacy and

Therapeutics, 37(7), 377. Retrieved March 19, 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411211/

Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a

literature review of disruptions to nursing practice during medication administration.

Journal of clinical nursing, 24(21-22), 3063-3076. Retrieved March 19, 2017, from

http://onlinelibrary.wiley.com/doi/10.1111/jocn.12944/full

Lambert, B. L., Schroeder, S. R., & Galanter, W. L. (2015). Does Tall Man lettering prevent

drug name confusion errors? Incomplete and conflicting evidence suggest need for

definitive study. Retrieved March 19, 2017, from

http://qualitysafety.bmj.com/content/25/4/213

Wollitz, A., & O'Conner, M. (2015). Medication Mix-Up: From Bad to Worse. Patient Safety

Network. Retrieved March 19, 2017, from https://psnet.ahrq.gov/webmm/case/343