Process phase | Risks* | Examples of LASA risks |
An epinephrine injection solution is needed at a strength of 1 mg/mL (high-alert medication) | ||
Written or verbal prescription from a doctor | Similar names:
| Hearing or reading the prescription incorrectly: Adrenaline 1 mg/mL is confused with Lidocain c. adrenaline 10 mg/mL+10 µg/mL. The error is facilitated if the indication is not known. |
The product is searched from the ADC using the generic name, brand name or identification number The product is selected and the dose is entered Repeated if several medicines for the same patient is needed | Similar names:
Similar identification numbers or Nordic article numbers | Searching a product using less than the first five letters, for example “adre” → the ADC offers seven different epinephrine products. Searching “adrenaliini” (“adrenalin”) → the ADC offers four different epinephrine products. A high risk of choosing the wrong preparation, for example, Adrenaline 0.1 mg/mL instead of Adrenaline 1 mg/mL, Adrenaline 0.1 mg/mL (5 mL) and Noradrenaline Hospira 1 mg/mL (4 mL) (noradrenaline or norepinephrine). Can be confused with each other as the products have a LASA risk caused by similar names and Nordic article numbers 536797 and 576786. |
Guided by the ADC, the required amount of product is removed from the package and the package is put back in place | Similar names or packaging: there are LASA medicines in the same storage unit | In the same refrigerator at similar storage sites (eg, 1 and 11) several different epinephrine preparations are placed side by side, for example Adrenaline 1 mg/mL (1 mL) and Adrenaline 0.1 mg/mL (5 mL). LASA risk based on the similar packaging, strength and names The outer package is missing → the ampoules look alike Due to a change in the medication selection or due to a shortage of medicines, the appearance or a brand name of the needed product has changed → higher risk to select a LASA medicine |
*The table does not take a stand on other possible medication errors, such as misdiagnosis or dose calculation errors.
LASA, look-alike, sound-alike.