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Morgan McMahon
Medication administration is a vital aspect of patient-centered care that nurses perform on a daily
basis. While the method of administering medication may be simple, the process of obtaining the
medication and giving it to the patient has many different avenues where medication errors can
occur and cause injury or even death to the patient. One common medication administration error
that occurs is caused by medications that sound-alike and/or look-alike (LASA). Due to the
Medication Error
Medication errors involving LASA drugs account to one in four medication errors in the
United States (Bryan, Aronson, Hacken, Williams, & Jordan, 2015). A LASA drug associated
medication error can occur when the nurse misreads or mishears a providers orders, obtains the
wrong LASA medication from the dispenser, or even confuses two different patients
medications due to the similarities between the sound and spelling. An example of a LASA
patient that requires midodrine, the patients blood pressure could potentially plummet, making
the patient even more hypotensive and increasing the risk for complications and death (Wollitz &
O'Conner, 2015). LASA associated drug medication errors are at an increased risk for occurring
when the nurse has many distractions throughout the medication administration process (Hayes,
Jackson, Davidson, & Power, 2015). Potential distractions that the nurse could encounter come
from a multitude of different sources including the patient receiving the medication, the nurses
LOOK-ALIKE SOUND-ALIKE RELATED MEDICATION ADMINIST 3
other patients, other health care professionals, colleagues, and family members. Because the
nurse has a large involvement in the direct care of the patient, distractions often occur every shift
(Hayes et al., 2015). The combination of distractions and LASA medications not only increases
the nurses chance of making an error, but also puts the patient at a higher risk for harm.
Nursing Interventions
Due to the high incidence of LASA associated medication errors, there have been
techniques and nursing interventions to ensure that the patient receives the right medication. One
intervention is the application of checking the six rights at three different and specific times
before giving the medication to the patient. The six rights include: right patient, right drug, right
dose, right route, right time, and right documentation. The nurse should check the six rights
when looking at the patients chart, pulling the medication out of the dispenser, and right before
giving the patient the medication in order to ensure patient safety (Hayes et al., 2015). Another
intervention that nurses can use to reduce distractions during medication administration is to
review the providers orders and the patients chart in a quiet space such as the med room. By
focusing and correctly identifying the right patient, medication, route, drug, time in a quiet area,
the nurse has a higher chance of correctly administering the medication and maintaining patient
safety (Grissinger, 2012). Although it is not a nursing intervention, one way that drug labeling
companies are trying to highlight the differences in LASA medications is through tall man
lettering. This technique is a visual aid for nurses to see the difference in look-alike medications
by capitalizing the unique letters of the medication name that is distinct from the look-alike drug
Personal Fear
When thinking about my future as a registered nurse, I am most afraid of the distractions
that nurses face on a daily basis when giving medication. My fear of giving the wrong
medication or wrong dosage is closely related to the amount of distractions that the nurse deals
with everyday, especially from the other patients. As a nurse, I want to care for each individual
equally and provide them with the full care that they deserve. In order to keep my medication
administration without error, I think I will take certain precautions when I am with a patient
giving medications. One of the biggest distractions that I have seen in the hospital is from the
phones that nurses carry with them during the day. When I am a nurse, I want to give my patient
my full attention, and unless there is an urgent situation, I will not answer my phone when
passing medications. I will also close the door and divide the room with the curtain to create a
more private space with the patient in order to decrease the possibility of distractions.
Conclusion
In conclusion, the nurse has an irreplaceable role in patient care, and an essential task that
the nurse completes is medication administration. One of the most significant causes of error
when passing medications involves the use of LASA drugs, and the incidence of errors is greatly
increased when the nurse encounters multiple distractions during the medication administration.
Due to the high occurrence of the LASA related medication errors, nursing interventions such as
identifying the six rights three times before administration, finding a quiet area to review the
medications before administration, and tall- man lettering are used to decrease the number of
medication errors. Nurses carry a large responsibility through giving medication, and their focus
during administration of medications can determine life or death situations for patients.
LOOK-ALIKE SOUND-ALIKE RELATED MEDICATION ADMINIST 5
References
Bryan, R., Aronson, J. K., ten Hacken, P., Williams, A., & Jordan, S. (2015). Patient safety in
nonproprietary names. PloS one, 10(12), e0145431. Retrieved March 19, 2017, from
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0145431
Grissinger, M. (2012). Physical environments that promote safe medication use. Pharmacy and
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411211/
Hayes, C., Jackson, D., Davidson, P. M., & Power, T. (2015). Medication errors in hospitals: a
Journal of clinical nursing, 24(21-22), 3063-3076. Retrieved March 19, 2017, from
http://onlinelibrary.wiley.com/doi/10.1111/jocn.12944/full
Lambert, B. L., Schroeder, S. R., & Galanter, W. L. (2015). Does Tall Man lettering prevent
drug name confusion errors? Incomplete and conflicting evidence suggest need for
http://qualitysafety.bmj.com/content/25/4/213
Wollitz, A., & O'Conner, M. (2015). Medication Mix-Up: From Bad to Worse. Patient Safety