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Look-alike, sound-alike medication errors: a novel case concerning a Slow-Na, Slow-K prescribing error

Authors Naunton M, Gardiner H, Kyle G

Received 3 December 2014

Accepted for publication 15 January 2015

Published 16 February 2015 Volume 2015:8 Pages 51—53


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 3

Editor who approved publication: Professor Ronald Prineas

Mark Naunton, Hayley R Gardiner, Greg Kyle

Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia

Abstract: A 59-year-old man was mistakenly prescribed Slow-Na instead of Slow-K due to incorrect selection from a drop-down list in the prescribing software. This error was identified by a pharmacist during a home medicine review (HMR) before the patient began taking the supplement. The reported error emphasizes the need for vigilance due to the emergence of novel look-alike, sound-alike (LASA) drug pairings. This case highlights the important role of pharmacists in medication safety.

Keywords: LASA, error, sodium, potassium

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