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Look Alike, Sound Alike (LASA) Medications

September 15, 2019

The Institute of Safe Medical Practices (ISMP) received two reports this year where vials of tranexamic acid were confused with either bupivacaine or ropivacaine because the bottles were similar in look, size, and had blue caps. This confusion led to patients receiving an intraspinal injection of tranexamic acid instead of the intended anesthetic which could result in seizures, permanent neurological injury, or paraplegia. Unfortunately, there have been numerous cases of accidental intraspinal injections of tranexamic acid due to look-alike / sound-alike (LASA) errors over the past few years.

LASA errors can occur when mediations are in similar looking packages, have similar generic or brand names, sound the same, or are available in varying strengths or formulations.

The Joint Commission standards encourage health care facilities to address LASA medications by:

  1. developing a list of LASA medications that the service unit stores, dispenses, or administers,
  2. updating and reviewing the LASA list annually, and
  3. taking action to prevent errors involving the LASA medications.

To assist in creating and updating a LASA list, the ISMP has developed a list of LASA medications Exit Disclaimer: You Are Leaving  called the "ISMP List of Confused Drug Names.” In addition to this list, please find attached is a handout with actions that you can take to reduce the risk of LASA medication errors at your health care facility.