title: Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.
abstract: BACKGROUND
  The acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of medication error jeopardizing patient safety are LASA as well as high workload.
  
  
  METHODS
  A critical incident report of medication errors of opioids for postoperative analgesia by look-alike packaging highlights the LASA aspects in everyday scenarios. A change to a generic brand of medication saved costs of up to 16% per annum. Consequently, confusion of medication incidents occurred due to the similar appearance of the newly introduced generic opioid. Due to consecutive underdosing no life-threatening situation arose out of this LASA based medication error.
  
  
  CONCLUSIONS
  Current recommendations for the prevention of LASA are quite extensive; still, in a system with a lump sum payment per case not all of these security measures may be feasible. This issue remains to be approached on an individual basis, taking into consideration local set ups as well as financial issues.
authors.affiliation: Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
authors.forename: Joerg
authors.initials: J
authors.lastname: Schnoor
authors.affiliation: Office of Quality and Risk Management, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Rogalski
authors.affiliation: Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
authors.forename: Roberto
authors.initials: R
authors.lastname: Frontini
authors.affiliation: Department of Anesthesiology, King's College Hospital Clinics Abu Dhabi LLC, Abu Dhabi, UAE ; Shining Towers, Mubarak bin Mohammed St, Khalidiyah, PO Box 129923, Abu Dhabi, UAE.
authors.forename: Nils
authors.initials: N
authors.lastname: Engelmann
authors.affiliation: Department of Orthopedics, Traumatolgy and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
authors.forename: Christoph-Eckhardt
authors.initials: CE
authors.lastname: Heyde
keywords: Costs; High work load; LASA; Look alike-sound alike; Medication error; Patient safety