Medication Safety For Medicines: Look-Alike, Sound-Alike

Medication safety for
look-alike, sound-alike
medicines
Medication safety for
look-alike, sound-alike
medicines
Medication safety for look-alike, sound-alike medicines
ISBN 978-92-4-005889-7 (electronic version)

ISBN 978-92-4-005890-3 (print version)
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Contents
Acknowledgementsiv
Acronymsv
Executive summary 1
1. Background 3
1.1 Purpose and methods 3
1.2 Look-alike, sound-alike (LASA) errors 4
2. The problem 5
2.1 Introduction 5
2.2 Examples 5
2.3 Scale of errors 8
3. Causes and impact of LASA errors 9
3.1 Stages of medication use at which LASA errors can occur 9
3.1.1 Prescribing 9
3.1.2 Transcribing or documenting 9
3.1.3 Dispensing 9
3.1.4 Administering 10
3.1.5 Monitoring 10
3.2 Clinical impact of LASA errors and vulnerable patients 10
4. Addressing LASA errors 11
4.1 Medicines as products to be addressed 11
4.1.1 Developing and updating the list of LASA medicines 12
4.1.2 “Tall man” lettering 12
4.1.3 Clear labelling, segregating storage and colour coding 13
4.2 Roles of patients and family members in preventing LASA errors 14
4.3 Roles of health and care workers in preventing LASA errors 14
4.3.1 Training of health and care workers 14
4.3.2 Roles of regulators, naming bodies and manufacturers 15
4.4 Health care systems and practices to be addressed 15
4.5 Additional points for consideration by member states and organizations 17
5. Barriers and enablers 18
5.1 Barriers 18
5.2 Enablers 18
References 19
Annex: glossary 23
Contents | iii |
Acknowledgements
Development of this document was coordinated by Neelam Dhingra-Kumar, Unit Head, Patient Safety Flagship, World
Health Organization (WHO) headquarters, Geneva, Switzerland.
The principal writing and editorial team at WHO headquarters: Priyadarshani Galappatthy, Alpana Mair, Neelam
Dhingra-Kumar, Minna Häkkinen-Wu, Ayda Taha, and Fumihito Takanashi.
Peer reviewers and other contributors, WHO headquarters: Pradeep Kumar Dua, Nikhil Gupta, Maki Kajiwara,
Aradhana Kohli, Shanthi Narayan Pal, Irina Papieva, Liu Qin, Kim Sungchol and Isabelle Wachsmuth.
Contributors from international organizations: Michael R Cohen, Institute for Safe Medication Practices,
USA; Helen Dowling, Australian Commission on Safety and Quality in health care; Carolyn Hoffman, Institute for
Safe Medication Practices, Canada; Zuzana Kusynová, International Pharmaceutical Federation; Caroline Samer,
International Union of Basic and Clinical Pharmacology; David U, International Medication Safety Network; and Steve
Waller, Australian Commission on Safety and Quality in health care.
Contributors from WHO regional offices: Gertrude Avortri (WHO Regional Office for Africa), Mafaten Chaouali
(WHO Regional Office for Europe), Jonas Gonseth-Garcia (WHO Regional Office for the Americas), Hyppolite Kalambay
Ntembwa (WHO Regional Office for Africa), Pierre Claver Kariyo (WHO Regional Office for Africa), Angeliki Katsapi
(WHO Regional Office for Europe), Mondher Letaief (WHO Regional Office for the Eastern Mediterranean), Nittita
Prasopa-Plaizier (WHO Regional Office for the Western Pacific), Joao Joaquim Rodrigues da Silva Breda (WHO Regional
Office for Europe), Aparna Singh Shah (WHO Regional Office for South-East Asia), Tomas Zapata (WHO Regional Office
for Europe) and Evgeny Zheleznyakov (WHO Regional Office for Africa).
The external peer reviewers: Loubna Alj, Morocco; Nana Kwame Asiamah, Ghana; Shane Byrnes, Ireland; Mahesh
Devnani, India; Lind Grant-Oyeye, Canada; Partha Gurumurthy, Botswana; Jesus Palacio Lapuente, Spain; Nagwa
Metwally, Egypt; Victor Mosweu, Botswana; Abeer Muhanna, Saudi Arabia; Andrew Smith, United Kingdom; and
Kazumi Tanaka, Japan.
| iv | Medication safety for look-alike, sound-alike medicines

Acronyms
CPOE computerized prescriber order entry
HICs high-income countries
ISMP Institute for Safe Medication Practices
LASA look-alike, sound-alike
LMICs low- and middle-income countries
T&CM traditional and complementary medicines
TML “tall man” lettering
USA United States of America
WHO World Health Organization
Acronyms |v|
Executive summary
Medication errors are a leading cause of patient harm not colour coding of different strengths, and storage of
globally. Look-alike, sound-alike (LASA) medicines are LASA medicine pairs close to one another can result in
a well-recognized cause of medication errors that are LASA errors during dispensing. Unclear instructions for
due to orthographic (look-alike) and phonetic (sound- administration, failure to double-check the order and
alike) similarities between medicines that can thus be failure to monitor the patient after administration can
confused. Look-alike medicines appear visually the lead to administration and monitoring errors. Failure to
same with respect to packaging, shape, colour and/ engage patients in their treatment at each stage of the
or size, while sound-alike medicines are similar in the medication use process results in LASA errors reaching
phonetics of their names, doses and/or strengths. the patients.
Confusions can occur between brand–brand, brand– The potential outcomes of LASA errors include
generic or generic–generic names. The similarities overdosing, underdosing or inappropriate dosing of
could also occur with products coming under unintended or intended medications. The impact on
traditional and complementary medicines (T&CM). the patient will depend on the medicine administered
The appearance of medicines can be misleading, both and patient factors. Patients in extremes of age or with
because different medicines appear to be the same or organ dysfunction are more vulnerable to errors and
because the same medicines appear to be different. severe harm because of their particular physiology.
This document provides information based on the best Furthermore, they are more prone to make errors and
available evidence on the extent of this problem, the be subjected to errors when dose modifications are
underlying causes and how to address them to prevent required. The impact of LASA errors involving high-risk
harm. (high-alert) medicines will be serious and can cause
severe patient harm, including death.
LASA errors can occur at any stage of medication use:
prescribing, transcribing or documenting, dispensing, Table 1 lists the main actions that can be taken on
administering and monitoring. Poorly legible medicines as products, by patients, health and care
handwritten prescriptions, verbal orders, use of error- workers, health care institutions, facilities and countries
prone abbreviations and selection of a LASA medicine to prevent or minimize LASA errors. Some of the
in computerized prescriber order entry (CPOE) are actions are common to more than one area but are
some of the main reasons for errors during prescribing. listed under only one, and several approaches may be
Similar appearance of medicines and their packaging, necessary.
Executive summary |1|

Table 1: Actions suggested for reducing LASA errors
Actions by health care
Actions on medicines as Actions by patients, Actions by health
facilities, institutions
products families and caregivers and care workers
and countries
1. Use “tall man” lettering 1. Know each medicine 1. Educate themselves 1. Promote a just, trusting
(TML) to label medicines prescribed, dispensed and the patients about culture in facilities so
with which a risk has and administered, the LASA medicines that staff are at ease in
been identified. including the name, that are prone to errors, discussing and reporting
indication, strengths of and address them in LASA medication errors
2. Segregate storage of
medicines dispensed and practice. (The section on and near misses.
identified LASA medicine
the dose to be used. improving medication
pairs or groups. 2. Identify the most
safety of the WHO patient
2. Be aware of potential common pairs of LASA
3. Develop and use tools safety curriculum guide
errors with LASA medicines in the country
and skills to identify is a good resource for this
medicines, and be or organization, and
LASA medicine pairs to purpose).
vigilant about such update the list regularly.
prevent registration of
errors. 2. Pay attention to LASA
such products, minimize 3. Label clearly, use TML,
medicines when
approval of several 3. Learn to label and store and segregate storage of
prescribing, dispensing
strengths of the same medicines appropriately LASA medicines.
and administering
medicine, and approve at home to avoid LASA
medicines and during 4. Take measures to
only dosage forms and errors with the medicines
medication reconciliation avoid interrupting and
strengths with different dispensed to the patient.
at transitions of care. distracting health and
appearances and
4. Check with the care workers while they
packaging. 3. Use generic names
health care provider are dispensing and
during prescribing and
4. Identify LASA medicines if in doubt, about a administering medicines.
transcribing to minimize
when including them in prescribed, dispensed
errors due to brand name 5. Include technology-
formularies and during or administered LASA
confusion. based solutions, such
purchase for institutions medicine.
as CPOE and barcoded
and countries. 4. Write legibly when
dispensing, to avoid
prescribing and
5. Prioritize LASA errors LASA errors.
transcribing.
involving high-risk
6. Apply quality control
medicines with greater 5. Attach clear labels for
measures to ensure
potential for severe harm. LASA medicines, with
proper use of authentic
TML for medicines that
6. Label all raw and herbal medicines.
could be confused.
processed T&CM
products including the
botanical names of plants
Each facility or institution should consider the barriers to in LASA errors. Engaging patients and families in
and enablers of implementing the activities suggested. recognizing LASA errors, developing a positive reporting
They will be specific to each facility and institution. Some culture, and establishing systems and practices for active
barriers that facilities and institutions could consider consideration of LASA medicines, (from procurement to
include a “blame culture”, staff fatigue, limited resources use of medicines by patients) would also reduce LASA
and the additional time necessary for staff for TML, errors.
labelling and segregating storage. A further barrier is
the absence of processes to identify many confusing This publication on medication safety for LASA
formulations or multiple strengths of the same medicine. medicines is based on the best currently available
evidence for action, which is presented when available.
Enablers for reducing LASA errors include the support For most of the proposed solutions, however, the
of institutions, regulators and manufacturers for evidence was based on work conducted in controlled
considering LASA medicines as products that can be environments, and the suggestions are based mainly on
confused and staff training in LASA errors, including expert consensus. More evidence, especially from real-
sharing information with patients and carers about life settings, would allow evidence-based strategies that
lettering, packaging and storage that could result could reduce errors due to LASA medicines.
|2| Medication safety for look-alike, sound-alike medicines

1
Background
In recognition of the scale of avoidable harm linked

with unsafe medication practices and medication errors,
1.1 Purpose and methods
WHO launched the third Global Patient Safety Challenge: This publication is part of a technical series on solutions
Medication without harm, in 2017, with the goal of to ensure medication safety. It is meant to provide a
reducing severe, avoidable medication-related harm resource for health and care workers, policymakers,
by 50% over 5 years, globally (1). The Challenge created health care facilities, institutions and patient care
the opportunity for leaders to drive change and work organizations to understand the problem and impact
together to make a real difference to the lives of patients, of LASA medicines and to detect, address and prevent
families and front-line health workers. Furthermore, to LASA errors. It also includes points for consideration
consolidate the activities of the Challenge, “Medication by Member States, organizations, manufacturers and
safety” was selected as the theme for World Patient regulators.
Safety Day 2022, with the slogan “Medication without
harm”. A literature search was conducted up to March 2023 in
PubMed, Google Scholar, Google and WHO publications
Interventions are necessary at global, regional, national with the keywords: look-alike sound-alike medicines,
and facility levels and on the front line to address LASA medicines, medication errors and serious harm.
the Challenge, as the causes of medication errors The relevant references in the reference lists of key
are complex, with many contributing factors. Unsafe published articles on LASA medicines were retrieved
medication practices leading to medication errors and reviewed. Information related to LASA medicines
jeopardize patient safety. A medication error is defined available on the websites of major medicines regulatory
“as any preventable event that may cause or lead to authorities and of other relevant organizations, such as
inappropriate medication use or patient harm while the Institute for Safe Medication Practices (ISMP), were
the medication is in the control of the health care also reviewed.
professional, patient, or consumer. Such events may be
related to professional practice, health care products, Expert opinion was obtained from relevant WHO
procedures, and systems, including prescribing, order units, WHO regional advisors and content experts.
communication, product labelling, packaging and An advanced draft was sent for critical review to a
nomenclature, compounding, dispensing, distribution, wider group of reviewers and patients’ representatives
administration, education, monitoring, and use” (2, 3). identified from the Global Patient Safety Network,
representing all WHO regions, including low- and
Background |3|
middle-income countries (LMICs). All comments received between brand or generic names. Sound-alike errors are
were considered in revising the document. All external due to medicines with names that can easily be mistaken
contributors and reviewers provided declarations for those of others, especially when verbal orders are
of interests and signed confidentiality agreements, given (4). There is, however, no universally accepted,
which were reviewed before they were invited to make clear definition of LASA errors. The appearance of
contributions. medicines can be misleading because other medicines
may look the same; conversely, the same medicine from
a different source may look different. LASA medication
1.2 Look-alike, sound-alike errors can occur due to similarities in the medicine
(LASA) errors name, dosage form, strength or product packaging.
These errors often occur due to selection of the wrong
Medication errors that occur when medicines have medicine from a shelf or even from an electronic list.
similar-looking or similar-sounding names, and/or
shared features of products or packaging are called Adverse events may also arise during the use of T&CM
LASA errors (4). LASA errors occur when the names of products due to mistaken use of the wrong species of
pairs or groups of medicines, such as cephalosporins, are medicinal plants leading to incorrect dosing of raw herbs
similar in both their written forms (orthography) or their or finished products.
spoken names (phonology). Confusion can also occur

2
The problem
2.1 Introduction countries, both high-income countries (HICs) and

LMICs now identify LASA medicines lists for their own
LASA errors constitute a high proportion of all settings (7–11).
medication errors that can lead to significant patient
harm (4). In recognition of the problem, the Food and
Drug Administration in the USA initiated a project 2.2 Examples
for name differentiation in 2001 to evaluate post-
LASA errors often occur due to similarities in the letters
marketing reports of confusion of name pairs (5).
that make up the names of different medicines or
Identification of LASA medicines is a requirement in
products, at the beginning, middle or end of the name
medication management standards in many countries
(Table 2). Table 3 lists LASA medicine pairs identified
and health care settings. The ISMP issues a regularly
in several countries, while Figure 1a and 1b presents
updated list of LASA medicines, which can be used
some examples of LASA medicines identified in clinical
as a guide to identify LASA medicine pairs (6). Many
settings.
Table 2: Mistaken letters in names of medicines

Location in the name Letters Examples of medicines
Beginning Am Amiloride, Amitriptyline, Amlodipine, Amiodarone
Az Azathioprine, Azithromycin
Carb Carbimazole, Carbamazepine
Pr Prochlorperazine, Propranolol, Prednisolone, Promethazine
Middle gaba Pregabalin, Vigabatrin
End azole Metronidazole, Omeprazole
The problem |5|

Table 3: Examples of LASA medicine pairs identified in selected countries (non-proprietary or generic name is
in parentheses)
Country Brand name (generic name) Brand name (generic name)
Australia Avanza (mirtazapine) Avandia (rosiglitazone)
Losec (omeprazole) Lasix (furosemide)
Bangladesh Maprocin (ciprofloxacin) Macrocin (erythromycin)
Brazil Losec (omeprazole) Lasix (furosemide)
Quelicin (succinilcolina) Keflin (cefalotina)
Canada Celebrex (celecoxib) Celexa (citalopram)
Losec (omeprazole) Lasix (furosemide)
France (fluoxetine) (fluvoxamine)
India Bandy (albendazole) Candy (clindamycin)
Ireland Losec (omeprazole) Lasix (furosemide)
(morphine) (hydromorphine)
Italy Diamox (acetazolamide) Zimox (amoxicillin trihidrato)
Flomax (morniflumato) Volmax (salbutamolo solfato)
Japan Almarl (arotinolol) Amaryl (glimepiride)
Taxotere (docetaxel) Taxol (paclitaxel)
Morocco Prazol (omeprazole) Prozac (fluoxetine)
Endoxan (cyclophosphamide) Triaxon (ceftriaxone)
Spain Dianben (metformin) Diovan (valsartan)
Sweden Avastin (bevacizumab) Avaxium (hepatitis A vaccine)
Lantus (insulin glargine) Lanvis (toguanine)
Source: WHO (12).
Figure 1a: Examples of some injectable products of LASA medicines identified
Ketamine hydrochloride (general anaesthetic and sedative) and Bupivacaine (local anaesthetic) and sodium chloride (intravenous
midazolam (benzodiazepine used as a sedative, and anxiolytic) fluid used as a diluent or to flush after intravenous cannulation)

Figure 1b: Examples of tablets of LASA medicines identified from LMIC settings
Diclofenac sodium 50 mg (nonsteroidal anti-inflammatory drug Gliclazide 80mg (anti diabetic medicine) and enalapril 5 mg (used
used for pain relief) and bisoprolol 5 mg (beta-blocker used for for hypertension and heart failure) These medicines are re-packed
cardiac failure and hypertension) from the original bulk packaging and kept for dispensing
Ciprofloxacin, levofloxacin (antibiotics) and several other medicines with similar

appearance kept for dispensing
LASA errors can occur due to confusion of the following With respect to the clinical impact of confusion of
name combinations; most LASA pairs are reciprocal. these medicines pairs, giving propranolol instead of
generic–generic names; for example, propranolol prednisolone to a patient with asthma has caused
and prednisolone, carbamazepine and carbimazole; exacerbation of asthma and hypotension, due to
propranolol aggravating bronchoconstriction and
brand–brand names, for example, Oxynorm and reducing blood pressure. Dispensing carbimazole,
Oxycontin, Losec and Lasix; Celebrex and Cerebryx; and an antithyroid medicine to a patient prescribed
brand–generic names, for example, Malarone and carbamazepine for epilepsy can have potentially
mefloquine. severe consequences as the patient can develop
The problem |7|

hypothyroidism and loss of seizure control. The brand– in different languages in different parts of the world,
brand confusion between Oxynorm and Oxycontin is an which could lead to wrong identification.
example of potential overdose if the modified release
preparation (Oxycontin) is given in place of the normal Figure 2: An example of look-alike different strengths
release product (Oxynorm) at regular intervals. In the of warfarin, an anticoagulant and a high-risk medicine
brand–generic example of Malarone and mefloquine,
although both are used against malaria, harm has
been seen when mefloquine used weekly was given
daily instead of weekly. Losec is a brand name for
omeprazole, an antiulcer treatment, while Lasix is a
brand name for frusemide, a diuretic. Celebrex is a brand
name for celecoxib, an anti-inflammatory medicine,
while Cerebryx is a brand name for fosphenytoin, an
anticonvulsant, which could also be confused with
Celexa, a brand name for citalopram, an antidepressant.
In these situations, a completely different medicine
from what was intended could be dispensed if the
prescription provides only the brand name, which could
have serious consequences for the patient.
Furthermore, the same brand name in the same or a

different country could have different active ingredients Note: Warfarin tablets of 1, 3 and 5 mg of the same colour were
and may result in administration of a completely different supplied to hospitals in bulk containers in a LMIC and dispensed to
patients as loose tablets. A patient was admitted with bleeding and an
medicine. For example, the brand name Medzol has been international normalizing ratio of 14.
given to both pantoprazole and midazolam, two different
medicines with different active ingredients (pantoprazole,
an antiulcer medicine and midazolam, a sedative). 2.3 Scale of errors
Sometimes, confusion can occur between two strengths LASA errors are estimated to be responsible for
of the same medicine. For example, warfarin is available 6.2–14.7% of all medication errors, with the prevalence
in strengths ranging from 1 to 10 mg, which are usually of LASA errors in prescriptions varying from 0.00003% to
colour coded. If colour coding is not used, serious errors 0.0022% (4). In the United Kingdom, where over 1 billion
could occur if 5-mg tablets are mistaken for 1-mg tablets prescriptions are issued each year, this error incidence
or vice versa (Figure 2). was estimated to result in up to 2.2 million LASA errors
annually (4).
LASA errors could also occur with T&CM products, which
are primarily based on medicinal plants. The confusions LASA errors often lead to administration of the wrong
could occur with raw herbs (root, stem or leaf of plants), medicine at the wrong or incorrect dose of the intended
processed herbs (powders, extracts or infusions) or medicine, leading to toxic effects or other adverse
finished products (syrups, fermented liquids, or polyherbal effects (13,14). External environmental factors are not
formulations). Similarity in the colour, consistency, aroma the cause, although they can increase the risk of an error
and the taste of the pieces of raw herbs, powders or liquid due to LASA medicines (15).
herbal preparations and colour, shape, size of the tablets
and capsules can contribute to LASA errors. Several Quantitative evidence of the prevalence of LASA errors is
medicinal plants are known by dissimilar common names limited, and various figures have been reported (Table 4).
Table 4: Reported prevalence rates of LASA errors

Rate of medication error due to LASA Type of study and reference
medicines
7% of medication near misses Systematic evaluation of 2044 near misses (16)
15% of vaccine errors Analysis of 607 error reports over 3 years in the USA (17)
0.0022% brand name confusion Total of 244 brand name confusions among 113 346 errors
reported in a study in Delhi, India (18).

3
Causes and impact of
LASA errors
To address the errors due to LASA medicines, the and lithium carbonate was dispensed instead of
instances in which they can occur must be identified. calcium carbonate, resulting in development of
LASA errors occur during all stages of medication use. lithium toxicity requiring dialysis. Writing only “U”
for ‘units’ has led to misinterpretation of “6U insulin”
as “60 units insulin”, which resulted in severe
3.1 Stages of medication use at hypoglycaemia.);
which LASA errors can occur Use of a trailing zero (for example, 5.0 mg can be
interpreted as 50 mg) or non use of a zero (for
LASA errors can occur at the stages of prescribing,
example, .5 mg instead of 0.5 mg can be interpreted
transcribing or documenting, dispensing, administering
as 5 mg), leading to dosing errors.
and monitoring (19). The common causes of LASA errors
at each of these stages are listed below.
3.1.2 Transcribing or documenting
3.1.1 Prescribing Incorrect transcription of a LASA medicine name;
Illegible or poorly legible handwritten prescriptions Use of inappropriate abbreviations in transcribing,

or orders, resulting in wrong interpretation leading to errors due to wrong interpretation of the
(particularly in LMICs, where handwritten abbreviation;
prescriptions are still used in most settings); Incorrect interpretation of sound-alike LASA
Verbal and telephone orders for medications, medicines due to lack of a read-back mechanism
resulting in potential confusion of sound-alike during verbal and telephone orders.
medications;
Non engagement of patients and families in 3.1.3 Dispensing
understanding and confirming the name and Selection of products according to where they
purpose of the medication; are stored in the pharmacy or according to the
Incorrect selection of medicines from look-alike packaging rather than the name and strength of the
products during CPOE; product;
Inappropriate use of error-prone abbreviations; for Storage of LASA medicines on the same shelf next
example, MSO4 can be interpreted as magnesium to each other, which may be picked up incorrectly
sulphate or morphine sulphate, resulting in serious during dispensing;
errors. (In one instance, CaCO3 was interpreted as Changing the appearance or packaging of
LiCO3 on an unclearly handwritten prescription, medicines, making them similar to other products;
Causes and impact of LASA errors |9|

Non use of colour coding for different strengths
and failure to recognize any changes in the usual
3.2 Clinical impact of LASA
strength or appearance of a product during errors and vulnerable patients
dispensing;
The impact on the patient will depend on the medicine
Failure to engage with patients to communicate the administered and the condition of the patient. LASA
name and purpose of the medication; errors can result in toxicity due to overdosing of a
Failure to double-check accurately during medicine, adverse effects of an unintended medicine,
dispensing due to time pressure, especially in LMICs and exacerbation of the disease for which the intended
when medicines are dispensed to a large number of medicine was not given. Some errors are detected
patients during one session; before the medicine is administered to a patient, while
others are not found until much later. Errors might be
Failure to communicate any changes in the
more common where there is lack of familiarity with the
appearance of medicines to patients.
products used (20).
3.1.4 Administering Some patient groups are more vulnerable to medication

errors than others, for example due to their physiology
Unclear instructions for administration, for example, in extremes of age, kidney or liver impairment, or frailty.
use of “as directed”, leaving instructions open to Potential for harm is higher in paediatric or elderly
misinterpretation; patients because of differences in physiology causing
Unfamiliarity with medicines, leading to selection of differences in pharmacodynamics and pharmacokinetics.
a look-alike product; Some factors related to the type of medicines also
Selection of a product according to familiarity with make the patients more vulnerable to severe harm
the packaging or strength rather than confirming due to errors. These include medicines with a narrow
and double-checking the medicine name and the therapeutic index, high-risk medicines, and medicines
dose; that are relatively more toxic, such as cancer medicines.
The use of acronyms or nicknames to refer to cancer
Failure to engage patients during administration of chemotherapy agents is also a potential source of error
medicines. (21). Patients in intensive care units and emergency
departments are also particularly vulnerable to errors.
3.1.5 Monitoring
Failure to monitor outcomes of medication by
relevant clinical observations or biochemistry.
| 10 | Medication safety for look-alike, sound-alike medicines

4
Addressing LASA errors
Limited evidence is available on the effectiveness of encourage reporting, monitoring and evaluation of
solutions for addressing the impact of LASA errors (4). common LASA errors, with regular review and revision
Although some regulatory bodies have taken steps to of common, country-specific pairs of LASA medicines.
minimize allocation of LASA names and appearances to
new products, situations can still arise in which similar Strategies to address LASA errors are considered below
names or appearances are assigned to medicines. under the four domains of the WHO third Global Patient
Idiomatic variation can also result in LASA errors in Safety Challenge: Medication without harm:
different pairs, depending on the country. Similar Medicines: medicines as products;
packaging should also be considered a potential cause Patients and the public: role of patients and family
of error. As LASA products are already on the market, members in preventing LASA errors;
targeted strategies are necessary to reduce the risk of
human error, with greater focus on a systems approach Health care professionals: role of health and care
rather than a person-centred approach to human workers in preventing LASA errors;
errors (22). Systems and practices of medication: health care
systems and practices to be addressed.
A systems approach has been shown to be more
effective in identifying the factors that are primarily
responsible for a risk of error, known as “latent 4.1 Medicines as products to
conditions” (22). Latent conditions can result in two
kinds of adverse effects: error-provoking conditions in
be addressed
the workplace (such as time pressure, understaffing, The most common reason for LASA errors is similarity
inadequate equipment, fatigue and inexperience) in names and packaging. Regulators and the
and long-lasting gaps or weaknesses in defences pharmaceutical industry both play roles in naming and
(for example, untrustworthy alarms and indicators, packaging medicines. Many errors could be prevented
unworkable procedures, and design and construction if manufacturers considered risks for LASA errors when
deficiencies). Member States, in collaboration with naming and designing packaging of medicines by
regulators, can develop programmes to encourage adherence to regulatory guidance. This is especially
their health and care institutions to address such latent important for risks that have already been identified.
conditions. National systems should be in place to
Addressing LASA errors | 11 |

4.1.1 Developing and updating to draw attention to dissimilarities between confusable
names.
the list of LASA medicines
Regulatory authorities determine whether TML could be
Each country or Member State needs to identify the used to help differentiate similar names after evaluating
most common pairs of LASA medicines in their country post-marketing reports of name pair confusion (5). Many
or organizations that cause errors and update them factors, such as the degree of similarity of the names
regularly. Systematic methods have been used by in a pair, the risks associated with name confusion,
countries and organizations to compile lists of such reports of medication errors, and causes or contributory
medicines (4-8). Separate lists of LASA medicines can factors, are considered during evaluation of name pairs.
be identified for different specialities and settings After evaluation, manufacturers can be requested to
(for example, for emergency care, intensive care voluntarily revise their labels by using TML (25,26). ISMP,
units, maternal and newborn care, oncology units or which updates the LASA list regularly (24), recommends
community pharmacy settings). If compilation of a use of TML in bold (Table 5). The list includes mostly
customized list is not possible, lists that have been generic–generic medicine name pairs, although some
developed by organizations such as the ISMP can be brand–brand or brand–generic name pairs are also
used (6). Organizations and countries can issue and listed, for voluntary use by health care workers, to
circulate regular bulletins to institutions to highlight and prevent LASA errors (26). Additional variations of TML,
address any issues as they arise (23). such as having letters in bold or in different colours, can
be used for easy identification.
4.1.2 “Tall man” lettering
TML is the only intervention that has been evaluated
One widely adopted approach for differentiating LASA for efficacy in preventing LASA errors in randomized
medicine pairs is the use of TML, a term coined by controlled trials. Although the intervention is
ISMP (24). TML assists in differentiating LASA medicine recommended and widely used, a systematic review of
names by the use of upper-case lettering for certain such trials found limited efficacy and concluded that
letters of medicines names. This has often been applied TML is marginally effective for reducing LASA
to syllables or groups of letters within a medicine name errors (13).
Table 5: Some LASA medicine names recommended for “tall man” lettering
Established name Recommended “tall man” lettering
Acetohexamide acetoHEXAMIDE
Acetazolamide acetaZOLAMIDE
Bupropion buPROPion
Buspirone busPIRone
Chlorpromazine chlorproMAZINE
Chlorpropamide chlorproPAMIDE
Clomiphene clomiPHENE
Clomipramine clomiPRAMINE
Cyclosporine cycloSPORINE
Cycloserine cycloSERINE
Daunorubicin DAUNOrubicin
Doxorubicin DOXOrubicin
Hydralazine hydrALAZINE
Hydroxyzine hydrOXYzine
Hydromorphone HYDROmorphone
Medroxyprogesterone medroxyPROGESTERone
Methylprednisolone methylPREDNISolone
Methyltestosterone methylTESTOSTERone
Source: Food and Drug Administration (5) and ISMP (6).

4.1.3 Clear labelling, segregating should be appropriately labelled to prevent errors in
selection.
storage and colour coding
Figure 3: Labelling for LASA medicines in which “tall-
The methods considered for addressing LASA errors are
man” lettering cannot be applied
based mainly on expert opinion and consensus (4,13).
Those who use the policies are encouraged to collect
evidence of their impact to contribute to the evidence
base. If TML cannot be used (for example, for vaccines
and immunoglobulins for a particular disease), the trade
name on the label could differentiate the two products.
Labelling that indicates possible LASA confusion can
also help to identify medicines for which TML cannot be
applied (Figure 3). Segregated storage of LASA medicine
pairs may also help to avoid errors (Figure 4) (27).
The few studies on use of a colour coding system

provide little evidence that it reduces the risk of errors
due to look-alike medicines (28). There are far more
look-alike medicines or medicine groups than there
are colours that could be used. Most importantly, the
evidence suggests that, when colour coding is used,
health and care workers may rely solely on the colour of
labels and not read them at all (29,30). Despite the lack of
evidence, an international standard recommends colour
coding of medicines used in anaesthesia, and it appears
to be the most widely used strategy for labelling such
medicines in many countries, including Australia, New
Zealand and the United Kingdom (30–32).
In T&CM products the common name of every

Source: Pharmaceutical Services Division, Ministry of Health,
medicinal plant written in English need to be
Malaysia (27)
supported by its scientific/botanical name on the label.
The small pieces of raw herbs used for making infusions Note: Proprietary (brand or trademark) names may be added to
distinguish medications. Non-proprietary names should be in larger
and decoctions, processed herbs and finished products font size than brand names.
Figure 4: Storage of LASA medicine pairs separately
Source: Pharmaceutical Services Division, Ministry of Health, Malaysia (27)

Note: Whenever possible, avoid storing LASA medicines close together.

4.2 Roles of patients 4.3.1 Training of health and care
and family members in workers
preventing LASA errors Lack of training or staff fatigue can contribute to LASA
Poor medication literacy among patients may errors. The section on “improving medication safety” in
contribute to LASA errors. In a study conducted the WHO publication, Patient safety curriculum guide,
in a French region, 768 patients were interviewed. multi-professional edition (35) is a good resource for
Although most patients identified medicines by their teaching and learning, as it addresses common causes of
brand name (50%) and generic name (21%), some medication errors and strategies for preventing patient
identified medicines by the physical appearance of the harm. Potential LASA errors should be included in
box (16%), tablet (7%) or blister packaging (3%) (33). graduate and postgraduate educational curricula and in
The factors considered most likely to cause confusion continuing professional development for all categories
were the appearance of medicines, including look- of health care providers. Health and care workers from
alike tablets (28%), look-alike boxes (20%) and all backgrounds should consider LASA errors when
look-alike blister packaging (13%) (33). Studies from selecting medicines during prescribing, dispensing and
LMICs indicate that patients in LMICs had much less when administering medicines. Research, including
knowledge than those in HICs about the medicines systematic reviews that included low-resource settings,
they took with only 42% identifying the medicines by has shown that, when users are aware of the purpose
their name (34). and use of TML, they are less likely to confuse look-
alike names and more likely to derive benefit from TML
Patients and families should learn about the medicines (20,36,37). Health and care workers should improve the
prescribed to them and be vigilant about LASA errors, understanding of patients of potential LASA errors at
for their own safety. Patient safety organizations can home, thus helping to prevent such errors. Development
educate patients about possible LASA errors. Reporting of a culture in which health and care workers listen to
of LASA errors by patients to the relevant authorities patients and their carers when they share information
can assist the authorities in learning from errors and in about administration of their medicines is important in
identifying local LASA pairs to prevent similar errors. preventing LASA errors (38).
Patients should also appreciate that the same medicine
Health care professionals, especially pharmacists and
from different sources may have different appearances.
nurses, should be trained in attaching clear labels with
This will help patients to avoid overdosing by taking
TML for LASA medicines and storing different strengths
the same medicine from two sources and with different
of the same medicine with similar packaging separately
physical appearances and may also help to improve
to avoid errors, especially for high-risk medicines. TML
adherence to a medicine with a familiar appearance that
should be used when a risk has been identified and not
is different when manufactured by another source.
in all circumstances (41).
Among consumers, there is a widespread misconception
that T&CM products are ‘natural’ and hence ‘safe’ and To engage patients and families, health and care workers
can:
carry no risk. However, errors in selection of T&CM
products and usage of incorrect and inappropriate T&CM educate patients, families and caregivers about
products can lead to unwanted effects and public should potential LASA errors and remind them to double-
be aware of this. check the names of their medicines;
teach them about use of TML on labels to help them
4.3 Roles of health and care identify the names clearly, even at home;
workers in preventing LASA educate them about the names used for their
errors medicines, (brand name and generic name, as
well as the clinical indication) so that patients are
Health and care workers around the world should engaged in ensuring that they receive the correct
be aware of LASA medicines and prevent errors in medication;
their practice. They should attach clear labelling support patients, families and caregivers in
and segregate storage of LASA medicines to ensure speaking about their medicines if they suspect any
differentiation. unexpected change;

educate patients about the problems of LASA encourages generic manufacturers of the same
medicine names so that they are aware before medicine to ensure that their products have similar
ordering medicines via the internet or in physical characteristics (44). Regulatory authorities
pharmacies, and encourage them to purchase recommend that sufficient visibility be given to
medicines from regulated, authorized premises; and generic names to facilitate identification, even if the
encourage patients to enquire about medicines proprietary name is different (45).
from their community pharmacists or health and
care workers, to seek information about LASA
medicines, and to keep a list of the medicines they
4.4 Health care systems and
are prescribed to prevent LASA errors related to practices to be addressed
their medications.
A just and trusting culture is fundamental to patient
safety in an organization. By ensuring that staff are at
4.3.2 Roles of regulators, naming ease in discussing and reporting potential LASA errors,
bodies and manufacturers the organization can prevent the same or similar types
of error from occurring. Staff must also be supported in
Regulators, naming bodies and manufacturers play vital proposing contributing factors and underlying reasons,
roles in ensuring that factors related to LASA medicines
such as a high workload, psychological aspects and
are considered during product development and
approval. identifying products prone to errors in their clinical
settings. Addressing such areas encourages health
Regulators are responsible for monitoring the workers to report errors and near misses (43). A whole-
naming and packaging of new products to avoid systems approach should be applied in identifying
LASA medicine errors. They are supported by an and addressing situations throughout the health care
international approach and discussion that allows system that could increase the likelihood of a LASA error.
LASA medicine pairs to be identified at the pre- An example is an emergency department or a busy
marketing stage (40). pharmacy, where more LASA errors could occur due to
Phonetic and orthographic computer analysis time constraints and a heavy workload. Steps to improve
can assist in naming new products, including systems and practices can contribute to preventing
consideration of variations in the products used errors in these high-risk situations.
in different countries. Phonetic and orthographic
Actions to address errors due to LASA medicines that
computer analysis does not, however, address the
could be implemented throughout a health care system
problem posed by existing products.
are given below.
The medicines regulatory authority in a country
can prevent registration of products with the same Avoid interruptions, distractions and verbal orders (15,
brand names but that contain different active 25, 46, 47):
ingredients or different strengths of medicines If verbal orders cannot be avoided, repeat the name
having the same appearance (see Figure. 2). out loud to confirm the exact verbal order and
Naming bodies, such the WHO International Non- clarify the name.
proprietary Names programme and the British Use signs stating “do not disturb” or “no interruptions”
Pharmacopoeia, can prevent designation of highly during medicines dispensing and administration; this
confusable name pairs (41,42). intervention has had various degrees of success, and
Manufacturers and suppliers should consider LASA there is also concern that it could discourage patients
errors when naming and packaging generic and from asking relevant questions.
branded medicines. Use reminders and alerts for LASA medicines.
Regulators can develop tools and skills to identify Be aware that high-intensity environments, such as
medication errors from reports of adverse incidents emergency departments, operating theaters and
from health care facilities and investigate their intensive care units, are particularly prone to LASA
preventability (43). errors.
Ensuring a similar appearance of generic products of Write legible prescriptions, and avoid use of error-
the same medicine would also aid in identification prone abbreviations (48-50).
of the same medicines from different sources.
If feasible, reduce the number of handwritten orders.
The Food and Drug Administration in the USA

Write the names of medicines, dosage directions prominent places, especially in pharmacies and
and route of administration legibly and consider critical care areas.
adding the indication to prescriptions to check the
Change the storage of medicines (46,56).
appropriateness of the prescription and to ensure
that LASA medicines are not confused. Change the sequence of storage of medicines with
similar sounding names, especially those with a
Verify prescriptions, for example by checking with
narrow therapeutic ratio.
the patient and reviewing the indication before
dispensing and administration. Segregate LASA medicines pairs or groups of
medicines, such as cephalosporins.
Record the identification of the prescriber (for
example, by using a seal) in both government and Use stickers with techniques such as TML, boldface
private sectors to facilitate clarifying any doubts and colour differences to reduce the confusion
about a prescription. associated with LASA medicines on labels, storage
bins, shelves, computer screens, automated
Be aware that poorly legible prescriptions and use of dispensing devices and medication administration
error-prone abbreviations are particular problems in records.
LMICs, where most prescriptions are written by hand.
Use colour coding to differentiate medicines,
Address packaging and labelling of LASA although a combination of techniques is advisable,
medicines, and provide information, education and especially for people who are colour blind.
communication material (51–55).
Review LASA medicines during registration of
Use typographic interventions, such as TML.
products, when including products in formularies, or
Use stickers with symbols or pictograms on during procurement of medicines (24,54).
packaging or signage on pharmacy shelves. Review potential problems before registering new
Relabel medicines to include brand and generic products or adding them to a formulary, including
names and use clear signage on pharmacy shelves. when introducing changes because of medicines
shortages.
If possible, request manufacturers and suppliers to
revise the labelling, appearance and packaging of Avoid adding several dosage forms of the same
their products, when similarities are noted medicine and limit the number of dosage forms and
(see figure 5). strengths available for adult and for paediatric use.
Display information, education and communication When procuring medicines, avoid purchasing
material about LASA errors and how to address medicines with similar packaging and appearance
them on boards, posters and other media at if possible; when introducing new products or
packages, compare them with existing packaging.
Figure 5: Revision of labelling and appearance of LASA medicines to minimize the risk of potential serious errors
Panel A Panel B
Source: Gangakhedkar et al. (56).
Note: Three high-risk medicines – rocuronium (muscle relaxant used in anaesthesia), midazolam (sedative) and heparin (anticoagulant) – in
similar bottles, (Panel A) with their appearances changed by differences in labelling and having caps of different colours after recognition of their
similarity and the ensuing risks (Panel B).

Use technology-based solutions to address LASA Report medication error incidents (43,47).
medicines (57–61)
Report medication error incidents and near misses
Design CPOE systems to ensure that LASA medicines in health care facilities by health and care workers
are not placed next to each other on the computer and by patients to the relevant authorities, in a “no
drop-down options and use other algorithms that blame” culture.
can reduce errors.
Perform root cause analysis by a multidisciplinary
Use indication alerts to intercept errors in medicine team to learn from errors and to implement
names and exercise caution to avoid alert fatigue coordinated actions to prevent common errors.
during CPOE.
Strengthen pharmacovigilance programmes and
Use barcoding during dispensing to correlate patient safety organizations to ensure that they
physical selection of a product with that on the report medication errors and near misses.
screen; however, checks should still be made, as this
Report errors related to T&CM products to learn
will not address errors occurring before dispensing,
from those and to take preventive actions.
such as during prescribing.
Consider use of automated dispensing cabinets and
robotic dispensing as a possibly useful intervention 4.5 Additional points for
to prevent dispensing errors.
consideration by Member
Use barcoding technology during administration
(when barcodes are added to products and to unit
States and organizations
dosages) with international standards for coding. Additional advocacy that can be taken to address LASA
Use a system for identifying pharmaceutical medicines is as follows:
products, when available, to reduce error; Ensure that organizations responsible for procuring
establishment of a global pharmaceutical product medicines include considerations of potential LASA
identification system is being discussed in the WHO errors in acquisition of new products.
Identification of Medicinal Products initiative
Be aware that a single brand name may be
(60, 61).
associated with different medicines in different
Undertake medication review and medication countries.
reconciliation (62,63). Advocate for increased emphasis on patient safety
Perform a medication review when initiating in the naming of medicines and for elimination
medications and at transitions of care. of LASA names by participating in national and
international regulatory, standards and advisory
Train pharmacists and other health and care workers
boards.
to address potential LASA errors on the wards and
at points of transition by performing medication Collaborate with international regulatory agencies
reconciliation, sharing information with patients and and industries to develop a uniform naming process
staff. and safety culture (64). This would require:
Ensure that all staff are properly trained and are aware a universal medicine naming convention;
of possible LASA errors and interventions to avoid them. screening of existing medicines names for
potential confusion with a new medicine name
Employ qualified, competent individuals for all steps in
before approval of the latter;
medication use and management in health care settings.
standardized suffixes (for example, for sustained-
Be aware that shortage of staff in many LMICs
release medicines);
has required the use of (often untrained and
unqualified) informal health care providers to assist ensuring that potential LASA confusions are
health and care workers, increasing the risk of LASA considered when medicines are introduced; and
errors; training of all categories of staff, including considering possible LASA errors due to
informal health care providers involved in handling similarities in packaging.
medicines is required, on possible LASA errors and
ways of preventing them.

5
Barriers and enablers
Each facility or institution should consider the barriers physicians’ preference for prescribing brand rather
to and enablers of implementation of solutions to LASA than generic names; and
errors. The lists below are not exhaustive, but facilities
insufficient evidence on solutions for LASA errors.
and institutions may consider them when developing
solutions to LASA errors.
5.2 Enablers
5.1 Barriers staff training, including sharing information about
blame culture; lettering and packaging with patients and carers to
minimize errors;
inadequate staff resources for TML and segregation
of LASA medicine pairs in storage; a positive reporting culture;
lack of appropriate formulations or strengths (for active consideration of LASA errors when procuring
example, paediatric doses or formulations and medicines;
different bolus and maintenance formulations); commitment of policy-makers and health care
inadequate resources, especially in LMICs, to leaders to minimize LASA errors; and
implement technological solutions such as CPOE collaboration among regulatory authorities and
and barcoding; responsible organizations to avoid LASA errors
wide variation in pharmaceutical regulations among during naming and packaging of medicines.
countries;
lack of a standard method for TML;

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Annex: glossary
Term Definition and source used (see references below)

Adverse drug event Any injury resulting from medical interventions related to a drug. This includes both
adverse drug reactions in which no error occurred and complications resulting from
medication errors (1).
Adverse drug reaction A response to a drug which is noxious and unintended and that occurs at doses used
in humans for prophylaxis, diagnosis or therapy of diseases, or for the modification of
physiological function (2). These are often classified as two types (3):
Type A adverse drug reaction: an augmented pharmacologically predictable reaction that
is dose dependent. It is generally associated with high morbidity and low mortality (4).
Type B adverse drug reaction: a bizarre reaction that is unpredictable pharmacologically
and is independent of dose. It is generally associated with low morbidity and high
mortality (4).
Formulary A list of medicines, usually by their generic names, and indications for their use. A
formulary is intended to include a sufficient range of medicines to enable medical
practitioners, dentists and, as appropriate, other practitioners to prescribe all medically
appropriate treatment for all reasonably common illnesses (5).
High-risk (high-alert) Drugs that bear a heightened risk of causing significant patient harm when they are used
medications in error. Although mistakes may or may not be more common with these medications,
the consequences of an error are clearly more devastating to patients (6).
Medication error Any preventable event that may cause or lead to inappropriate medication use or patient
harm while the medication is in the control of the health care professional, patient, or
consumer. Such events may be related to professional practice, health care products,
procedures, and systems, including prescribing, order communication, product labelling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use. (7).
Medication The formal process in which health care professionals partner with patients to ensure
reconciliation accurate and complete medication information transfer at interfaces of care (8).
Medication-related Patient harm related to medication (9). It includes preventable adverse drug events
harm (for example, due to a medication error or accidental or intentional misuse) and non-
preventable adverse drug events (for example, an adverse drug reaction).
Annex: glossary | 23 |
Term Definition and source used (see references below)
Medication review A structured evaluation of a patient’s medicines with the aim of optimizing medicine
use and improving health outcomes. This entails detecting drug-related problems and
recommending interventions (10).
Medication safety Freedom from accidental injury during the course of medication use; activities to avoid,
prevent, or correct adverse drug events that may result from the use of medications (11).
Medication use process The multistep process in the use of medications by or for patients, including prescribing,
ordering, storage, dispensing, preparation, administration and Monitoring (12).
Near miss An incident that did not reach the patient (13).
Patient safety The absence of preventable harm to a patient and reduction of risk of unnecessary harm
associated with health care to an acceptable minimum. An acceptable minimum refers to
the collective notions of given current knowledge, resources available, and the context in
which care was delivered weighed against the risk of non-treatment or other treatment
(13).
Pharmacovigilance Science and activities relating to the detection, assessment, understanding and
prevention of adverse effects or any other drug-related problem (2).
Safety The reduction of risk of unnecessary harm to an acceptable minimum (14).
Transitions of care The various points where a patient moves to, or returns from, a particular physical
location or makes contact with a health care professional for the purposes of receiving
health care (8).
Glossary references
1. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, 6. High-alert medications in community/ambulatory
Leape L. Relationship between medication errors settings. Institute for Safe Medication Practices;
and adverse drug events. Journal of General Internal 2011. (https://www.ismp.org/sites/default/files/
Medicine. 1995;10(4):199–205. https://link.springer. attachments/2017-11/highAlert-community.pdf
com/article/10.1007/BF02600255 accessed 25 March 2023).
2. The importance of pharmacovigilance: safety 7. About medication errors. What is a medication error?
monitoring of medicinal products. Geneva: World Rockville (MD): National Coordinating Council for
Health Organization; 2002. (https://apps.who.int/iris/ Medication Error Reporting and Prevention; 2019
handle/10665/42493 accessed 25 March 2023). (http://www.nccmerp.org/about-medication-errors,
accessed 25 March 2023).
3. Yellow Card Scheme: making medicines safer.
Guidance on adverse drug reactions. London: 8. Medication safety in transitions of care. WHO/UHC/
Medicines and health care Products Regulatory SDS/2019.9. Geneva: World Health Organization;
Agency; 2019 (https://assets.publishing.service.gov. 2019 (https://www.who.int/publications/i/item/WHO-
uk/government/uploads/system/uploads/attachment_ UHC-SDS-2019.9 accessed 25 March 2023).
data/file/403098/Guidance_on_adverse_drug_
9. Bates DW, Boyle DL, Vander Vliet MB, Schneider
reactions.pdf, accessed 25 March 2023).
J, Leape L. Relationship between medication
4. International Drug Surveillance Department. Drug errors and adverse drug events. J Gen Intern Med.
safety: a shared responsibility. Edinburgh: Churchill 1995;10(4):199–205. https://www.ncbi.nlm.nih.gov/
Livingstone; 1991. (https://onlinelibrary.wiley.com/ pubmed/7790981
doi/abs/10.1002/pds. 2630010210 acessed
10. Medication review: definition approved.
25 March 2023).
Zuidlaren: Pharmaceutical Care Network
5. A glossary of terms for community health care Europe; 2019.(https://link.springer.com/
and services for older persons. Geneva: World chapter/10.1007/978-3-319-92576-9_1 accessed
Health Organization; 2004 (https://apps.who.int/iris/ 25 March 2023).
bitstream/handle/10665/68896/WHO_WKC_Tech.
11. Committee of Experts on Management of Safety and
Ser._04.2.pdf?sequence=1%20&isAllowed=y, accessed
Quality in health care. Glossary of terms related to
25 March 2023).
patient and medication safety. Strasbourg: Council

of Europe; 2005.(http://www.who.int/patientsafety/ Health Organization; 2009 (http://apps.who.int/
highlights/COE_patient_and_medication_safety_ iris/bitstream/handle/10665/70882/WHO_IER_
gl.pdf accessed 25 March 2023). PSP_2010.2_eng.pdf?sequence=1, accessed
25 March 2023).
12. Vogenberg FR, Benjamin D. The medication-
use process and the importance of mastering 14. Definitions of key concepts from the WHO
fundamentals. P T. 2011; 36(10):651-2. PMID: patient safety curriculum guide. Geneva: World
22346298; PMCID: PMC3278147. https://www.ncbi. Health Organization; 2012. (https://www.who.int/
nlm.nih.gov/pmc/articles/PMC3278147/ publications/i/item/9789241501958 accessed
25 March 2023).
13. Conceptual framework for the international
classification for patient safety. Geneva: World
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Medication safety for

ISBN 978-92-4-005889-7 (electronic version)

© World Health Organization 2023

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Design and layout: Macro Graphics Pvt. Ltd., India

| iv | Medication safety for look-alike, sound-alike medicines

CPOE computerized prescriber order entry

HICs high-income countries

ISMP Institute for Safe Medication Practices

LASA look-alike, sound-alike

LMICs low- and middle-income countries

T&CM traditional and complementary medicines

TML “tall man” lettering

USA United States of America

WHO World Health Organization

Executive summary |1|

|2| Medication safety for look-alike, sound-alike medicines

In recognition of the scale of avoidable harm linked

|4| Medication safety for look-alike, sound-alike medicines

2.1 Introduction countries, both high-income countries (HICs) and

Table 2: Mistaken letters in names of medicines

The problem |5|

Figure 1a: Examples of some injectable products of LASA medicines identified

|6| Medication safety for look-alike, sound-alike medicines

Ciprofloxacin, levofloxacin (antibiotics) and several other medicines with similar

The problem |7|

Furthermore, the same brand name in the same or a

Table 4: Reported prevalence rates of LASA errors

|8| Medication safety for look-alike, sound-alike medicines

 Illegible or poorly legible handwritten prescriptions  Use of inappropriate abbreviations in transcribing,

Causes and impact of LASA errors |9|

3.1.4 Administering Some patient groups are more vulnerable to medication

| 10 | Medication safety for look-alike, sound-alike medicines

Addressing LASA errors | 11 |

| 12 | Medication safety for look-alike, sound-alike medicines

The few studies on use of a colour coding system

In T&CM products the common name of every

Figure 4: Storage of LASA medicine pairs separately

Source: Pharmaceutical Services Division, Ministry of Health, Malaysia (27)

Addressing LASA errors | 13 |

| 14 | Medication safety for look-alike, sound-alike medicines

Addressing LASA errors | 15 |

| 16 | Medication safety for look-alike, sound-alike medicines

Addressing LASA errors | 17 |

| 18 | Medication safety for look-alike, sound-alike medicines

| 20 | Medication safety for look-alike, sound-alike medicines

| 22 | Medication safety for look-alike, sound-alike medicines

Term Definition and source used (see references below)

| 24 | Medication safety for look-alike, sound-alike medicines

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Illegible or poorly legible handwritten prescriptions Use of inappropriate abbreviations in transcribing,