Look-alike, Sound-alike Research Articles

LASA (Look Alike Sound Alike) medicament errors - What a dental personnel needs to know?

LASA (Look Alike Sound Alike) medicament errors - What a dental personnel needs to know?

STOPP-START Criteria Used to Identify the Elderly Population Prone to Potentially Inadequate Prescribing in a Colombian Cohort.

Elderly people have multiple comorbidities that often require treatment with multiple medications. Having strategies to lessen the risks associated with pharmacological interactions and potentially inadequate prescribing (PIP) is of major importance. The STOPP- START criteria are useful in identifying PIP along with other tools, such as LASA (look alike/sound alike) drugs and high-risk medications (HRM). We aimed to clinically and sociodemographically characterize the population with PIP according to the STOPP-START criteria in hospitalized elderly patients over 6 months in a third-level hospital in Colombia, South America. We also aimed to calculate the prevalence of PIP, LASA drugs and HRM and to identify other problems related with medication. Finally, we proposed an algorithm for the identification of PIP in this population. This was a descriptive, cross-sectional study in hospitalized patients older than 60 years during the first semester of 2021 to identify PIP according to STOPP- START criteria. An analysis of clinical and sociodemographic variables was conducted, as well as the construction of an algorithm to identify PIP in the elderly in a semiautomated way. Data were collected and analyzed using the software SPSS 2021, using descriptive statistics and measures of central tendency. The prevalence of PIP in the study population was 25%. Furthermore, 60% of patients had one problem related to medication, and 27% used at least one LASA drug or HRM. This study allows one to characterize, for the first time, the Colombian population prone to PIP, as well as the construction of an algorithm that identifies PIP in a semiautomated way.

Ability of machine-learning based clinical decision support system to reduce alert fatigue, wrong-drug errors, and alert users about look alike, sound alike medication

Background and objectiveThe overall benefits of using clinical decision support systems (CDSSs) can be restrained if physicians inadvertently ignore clinically useful alerts due to “alert fatigue” caused by an excessive number of clinically irrelevant warnings. Moreover, inappropriate drug errors, look-alike/sound-alike (LASA) drug errors, and problem list documentation are common, costly, and potentially harmful. This study sought to evaluate the overall performance of a machine learning-based CDSS (MedGuard) for triggering clinically relevant alerts, acceptance rate, and to intercept inappropriate drug errors as well as LASA drug errors. MethodsWe conducted a retrospective study that evaluated MedGuard alerts, the alert acceptance rate, and the rate of LASA alerts between July 1, 2019, and June 31, 2021, from outpatient settings at an academic hospital. An expert pharmacist checked the suitability of the alerts, rate of acceptance, wrong-drug errors, and confusing drug pairs. ResultsOver the two-year study period, 1,206,895 prescriptions were ordered and a total of 28,536 alerts were triggered (alert rate: 2.36 %). Of the 28,536 alerts presented to physicians, 13,947 (48.88 %) were accepted. A total of 8,014 prescriptions were changed/modified (28.08 %, 8,014/28,534) with the most common reasons being adding and/or deleting diseases (52.04 %, 4,171/8,014), adding and/or deleting drugs (21.89 %, 1,755/8,014) and others (35.48 %, 2,844/ 8,014). However, the rate of drug error interception was 1.64 % (470 intercepted errors out of 28,536 alerts), which equates to 16.4 intercepted errors per 1000 alerted orders. ConclusionThis study shows that machine learning based CDSS, MedGuard, has an ability to improve patients’ safety by triggering clinically valid alerts. This system can also help improve problem list documentation and intercept inappropriate drug errors and LASA drug errors, which can improve medication safety. Moreover, high acceptance of alert rates can help reduce clinician burnout and adverse events.

Identification of Confusing Medicine Proprietary Names: Toward Safe Medicine Use-A Cross-Sectional Study in Sri Lanka.

Look-alike sound-alike (LASA) medications have similar pronunciation (phonetic) and/or manifestation (orthographic), which could create confusion among users and challenge the safe use of medicines. The availability of foreign products in local markets aggravates the situation. This study was designed to examine the registered medicine proprietary names in Sri Lanka to discern the presence of similar medicine names in the industry. A cross-sectional study was conducted on the registered drug proprietary names in Sri Lanka. Using the RAND and RANK functions in Microsoft® excel® 365, a random sample of 385 proprietary names was selected. Two evaluators independently evaluated each proprietary name in the sample against the other registered proprietary names following a stepwise text filtering method. After each filter, the resulting proprietary names were manually examined for identical, similar-looking, and similar-sounding proprietary names to the name under evaluation. The observations were matched, categorized, and collated into ten groups. Among the 385 names evaluated, 138 (35.84%) proprietary names had no similarity to existing other registered proprietary names. The rest of the names (n = 247, 64.15%) were found to be either identical (n = 03 pairs), look-alike (n = 91 pairs), or sound-alike (n = 80 pairs) to the registered proprietary names. The findings revealed the presence of equal and similar proprietary names in the system. A multifactorial strategy led by the National Medicine Regulatory Authority (NMRA) is recommended to minimize the confusing names entering the system. Primarily the NMRA's call for action should include adequate industry guidance with specific guidelines, a significant pre-submission assessment process, and denying approval of LASA proprietary names.

Implementation of Drug Administration with High Awareness (LASA/ Look Alike Sound Alike and High Alert) for Patient Safety at Pharmacies in Surakarta

LASA (Look Alike Sound Alike) are drugs that have similar names, looks and speech and need to be watched out for to prevent no errors in taking medication (dispensing error) by pharmacists. High-alert (HA) medication is a drug that must be watched out for because it often causes errors or serious errors (sentinel events) and drugs that have a high risk of causing Adverse Drug Reactions (ADR). One of the pharmacist duties at a pharmacy is to organize LASA and HA drugs properly to prevent medication errors. The purpose of this study is to determine the knowledge of pharmacist in the city of Surakarta on the process of good and safe drug storage and able to implement safe and high alert drug storage for patient/consumer safety. The type of research is experimental research. The study was conducted from September 1, 2021 to January 20, 2022. The number of samples were 117 pharmacists who worked in different pharmacy locations. The data obtained were scored and analyzed using the SPPS 25 test, the Shapiro-Wilk normality test, followed by the Paired sample T-Test. The results of this study indicate that there is an effect of socialization intervention using the HA and LASA flyer, namely an increase in knowledge and implementation of the arrangement of HA and LASA drugs. Data showed that the results of pre-test 17.52% and post-test 89.74% (p=0.000; p0.05). From this study, it was found that there was a significant change in the level of implementation of the LASA and HA drug arrangement from pharmacists after the intervention using the LASA/HA drug arrangement flyer.

Measuring drug name similarity to prioritise the application of tall-man lettering in a computerised pharmacy dispensing system

Abstract Introduction Medicine name similarity is a contributory factor to medication errors.1 Published lists exists highlighting medicine pairs that are easily confused; locally a Look-Alike-Sound-Alike (LASA) list has expanded over time with no formal system of triage. A multipronged approach is required to address LASA risks. Tall-Man Lettering (TML) is one intervention that uses uppercase lettering for the dissimilarities in look-alike drug names to alert staff to the risk of error.1 For greatest impact, it should be reserved for pairs with the highest risk for patient safety. Aim This study aimed to use Levenshtein Distance (LD), Bigram (Bi) and Trigram (Tri) methods to prioritise medicine pairs for TML in the Pharmacy dispensing system. Objectives were to: Produce a comprehensive list of medicines pairs; Establish normalised thresholds from LD, Bi and Tri to prioritise medicine pairs for TML; and, measure drug name similarity using validated software2 applying LD, Bi and Tri to medication pairs as a method of triage for orthographic assessment. Methods Approval was obtained by the Trust Pharmacy Research Committee. The need for ethical submission was waived. A LASA list was developed combining medicine name pairs from National Pharmacy Association list3, historical local list and internal incidents where medicine name confusion was cited. Duplicated, branded and non-stock pairs were excluded. A literature search was undertaken to identify published thresholds for accuracy and sensitivity of the methods in the measure of medicine name similarity. LD measures the minimum number of edit operations needed to transform one string into another; Bi and Tri measures the frequency in which two/three similar sequential strings appear within a medicine name respectively. Two assessors independently entered medicine pairs through a validated computer program2 applying LD, Bi and Tri to measure orthographic similarity. Normalised computed similarity scores (between 0-1 where higher values represent increased drug similarity) were collated on Microsoft excel for comparison against thresholds. Results Two-hundred and twelve medicine pairs were identified for review. The literature defined Bi and Tri thresholds at ≥0.3 and ≥0.1 respectively; in absence of this for LD, in-house thresholds were assessed then defined at ≥0.6. LD identified 84 medicine pairs; Bi identified 144; and Tri identified 158; none were uniquely found by LD, four by Bi and 18 by Tri. A final look-alike list with 82 medicine pairs meeting all three thresholds was identified for TML. Discussion/Conclusion Screening using all three methods led to a 61% reduction in medicines pairs allowing prioritisation of TML as an effective intervention based on look-alike pairs with the highest risk of error. This study focused on identifying orthographic similarity in ‘look-alike’ medicine pairs only. With no single intervention available to prevent LASA errors, future work can explore other interventions. In the absence of literature around normalised LD, the definition of an in-house threshold posed to be another limitation and an area where further exploratory work should be considered. As new LASA incidents arise or the Trust catalogue increases, these methods should be applied to triage their look-alike potential, confirming if TML is an appropriate intervention.

Therapeutic Error: Types and Prevention Strategies and Focus about "Look Alike/Sound Alike" and "High Risk" Drugs

Introduction: Therapeutic errors are among the main causes of drug-related problems, in terms of enhanced toxicological or reduced therapeutic effect, and concern all stages of the drug chain, from manufacturing to prescription, dispensing and administration. Everyone, pharmacists and doctors in all settings, should be aware of how to prevent and manage them and which drugs are at greatest risk. In this article we will focus on LASA (look alike/sound alike), on FAR (high-risk drugs) and on the guidelines especially for prevention.
 Methods: The article is a minireview that was written by research in paper and online on PubMed and Embase. We performed a search of any publications available in these databases between the years 1990 and 2022, using the key words: therapeutic errors, misuse / diversion of drugs, drug poisoning. After a review of the titles and abstracts, the articles chosen were considered relevant in providing evidence of the problem. We also added personal knowledge about the topic of the article and used some paper documents.
 Discussion and Conclusions: Most of the errors in therapy occur during administration, due to errors in doses, posology or interactions or incorrect manipulations of pharmaceutical forms, and in dispensing, due to incorrect interpretation of the prescription or confusion on the packaging in the case of LASAs. Pharmacists and doctors but also patients themselves should pay attention to the time of prescription and doctors to the drug history not only for interactions but also to avoid making mistakes in patients who take drugs with names or packages similar to the one described above. Moreover, attention must be paid in writing the prescription, in dosage, and pharmaceutical forms. Particular attention should be paid to handling by children and to avoiding any misuse of the medicines themselves.

Implementation of six patient safety goals at a public health centre with in-patient services in Bali, Indonesia: A qualitative case study

Background and purpose: The Indonesian government requires all health care facilities including public health centres (PHCs) to implement a patient safety program as part of the accreditation standard process. The implementation of patient safety in PHCs have faced various problems, including human resources and infrastructure issues. This study aims to explore the implementation of patient safety target procedures in an accredited inpatient PHC in Tabanan District, Bali, Indonesia.Methods: We conducted a qualitative case study that adopts four main domains in patient safety, consisting of executive officers, community or patient who received services, systems in service delivery and methods, and elements in each domain. The research location was at Penebel I PHC, an inpatient PHC with the accreditation status of “utama”. Data collection was carried out from March to April 2020. It includes observation of the patient safety implementation, review on tracking patient safety documents and in-depth interviews with 11 informants who are PHC staff, patients’ safety task force and the family of patients. The data were analysed using thematic analysis by creating a grid of themes, sub-themes and data reduction to narrative presentation. Results:The patient safety procedure in Penebel I PHC has been carried out through the standard and procedure according to the Ministry of Health (MoH) regulation which consist of patient identification; communication between staff and patients; maintain the safety of High Alert and Look Alike Sound Alike (LASA) medications. However, there is a need to improve the capacity of implementing officers to increase their communication competencies as well as to enhance cooperation between officers in health services to avoid patient safety incidents. Conclusion:The implementation of six patient safety goals in-corporate through four main domains of health care services has been running according to the MoH’s standard. There is a need to improve the competence of officers, cooperation between officers in carrying out patient safety management and improve communication between officers and patients so that the information conveyed by officers is truly understood by patients.

Evaluasi Penyimpanan Obat High Alert Di Instalasi Farmasi Rumah Sakit Juanda Kuningan

ABSTRACT
 High alert drugs are drugs that cause a high risk when there is an error in the administration. According to Decree No. 72 of 2016 the high alert category became 3, including LASA (Look Alike Sound Alike), High concentration electrolytes and Sitostatic. The purpose of this study is to find out the picture and suitability of high alert drug storage at the Juanda Kuningan Hospital Pharmacy Installation.This study is descriptive, the population and samples in this study are all high alert drugs in the Juanda Kuningan Hospital Pharmacy Installation. Data collection is done using a checklist sheet. Checklist refers to the standard of storage according to PerMenkes RI No. 72 of 2016. The study was conducted in April-May 2021.The results showed high alert drugs in accordance with PerMenkes RI No. 72 of 2016 with a 100% conformity percentage in high alert drug storage, LASA drug storage (Look Alike Sound Alike) or NORUM (Similar Speech Type Drug Name) and storage of Concentrated Electrolyte Concentrate drugs.
 
 Keywords : Storage, High Alert Drugs, Juanda Kuningan Hospital Pharmacy Installation

Medication errors in Najran, Saudi Arabia: Reporting, responsibility, and characteristics: A cross-sectional study

BackgroundMedication error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Disclosure of medication errors and improvement of patient safety are inexorably related, and they provide one of the strongest reasons to report and disclose errors, including near misses in which no harm comes to the patient. This study aimed to identify medication errors at the southern province of Saudi Arabia. MethodsA cross-sectional retrospective study was conducted by reviewing all medical records in the King Khaled Hospital in Najran, Saudi Arabia. Medication errors related information were extracted from the electronic medical system for the duration between 2018 and 2020. ResultsDuring the study period of 2018 to 2020, a total of 4860 medication errorswere identified. More than half of the reported medicationerrors (66.9%) were linked to ordering, prescribing, or transcribing medications. The most commonly reported medicationerrors connected to ordering/prescribing/transcribing were inappropriate dosage, dosage units, and therapeutic duplication of medication. The most commonly reported medication errors linked to administration were missing documentation during administration, not performing independent double-checks during the administration of high alert medications, and the administration of look-alike sound-alike (LASA) medications. The intensive care unit (ICU), female medical ward, and male medical ward were the most commonly reported locations for medication errors. Pharmacists detected more than half of the reported medication errors. Physicians were found to be responsible for 66.0% of reported medication errors, followed by nurses. ConclusionMedication errors are common in hospital settings in Saudi Arabia's southern provinces. Efforts should be made to improve drug ordering, prescribing, and transcription in hospital settings. To guarantee optimum practices, the entire medical team should take responsibility for the patient's optimal medication administration.

Profile of Storage System of LASA Drug Services in a Pharmacy, Besuki District, Situbondo Regency

The development of drug production is relatively rapid, causing several drugs that have almost the same shape, name, and packaging. This can cause medication errors in the form of errors in administering drugs to patients. Drugs that are nearly the same shape and name are known as LASA (Look Alike Sound Alike) drugs. This study aimed to determine the profile of the LASA drug storage and service system at pharmacies in Besuki District, Situbondo Regency. This research includes qualitative research through in-depth interviews and direct observation. The sample used in this study is a saturated sample. The results showed that the LASA drug storage system in pharmacies throughout Besuki District, Situbondo Regency only implemented a system of giving the distance between drugs one and other drugs, while other provisions for storing Lasa drugs were not carried out. The LASA drug service system is carried out by conducting double checks, memorizing various LASA drugs, and contacting doctors to clarify prescriptions for LASA drugs. Based on these results, it can be concluded that pharmacies in Besuki District, Situbondo Regency, do not meet the criteria in the LASA drug storage system. Meanwhile, in the LASA drug service system, pharmacies throughout Besuki District, Situbondo Regency have met the requirements for LASA drug services.

Implementation of six patient safety goals at a public health centre with in-patient services in Bali, Indonesia: A qualitative case study

Background and purpose: The Indonesian government requires all health care facilities including public health centres (PHCs) to implement a patient safety program as part of the accreditation standard process. The implementation of patient safety in PHCs have faced various problems, including human resources and infrastructure issues. This study aims to explore the implementation of patient safety target procedures in an accredited inpatient PHC in Tabanan District, Bali, Indonesia.Methods: We conducted a qualitative case study that adopts four main domains in patient safety, consisting of executive officers, community or patient who received services, systems in service delivery and methods, and elements in each domain. The research location was at Penebel I PHC, an inpatient PHC with the accreditation status of “utama”. Data collection was carried out from March to April 2020. It includes observation of the patient safety implementation, review on tracking patient safety documents and in-depth interviews with 11 informants who are PHC staff, patients’ safety task force and the family of patients. The data were analysed using thematic analysis by creating a grid of themes, sub-themes and data reduction to narrative presentation.Results: The patient safety procedure in Penebel I PHC has been carried out through the standard and procedure according to the Ministry of Health (MoH) regulation which consist of patient identification; communication between staff and patients; maintain the safety of High Alert and Look Alike Sound Alike (LASA) medications. However, there is a need to improve the capacity of implementing officers to increase their communication competencies as well as to enhance cooperation between officers in health services to avoid patient safety incidents.Conclusion: The implementation of six patient safety goals in-corporate through four main domains of health care services has been running according to the MoH’s standard. There is a need to improve the competence of officers, cooperation between officers in carrying out patient safety management and improve communication between officers and patients so that the information conveyed by officers is truly understood by patients.

Education strategy for the implementation of oncology biosimilars essential for operational and patient safety in Alberta, Canada.

Medication errors involving look alike sound alike (LASA) medications have widely been recognized to contribute to patient harm. Oncology biosimilars are considered to be LASA medications and require additional measures for operational safety. The Cancer Care Alberta (CCA) Pharmacy Educators developed an education strategy to ensure operational and patient safety during the implementation phase for oncology biosimilars in Alberta, Canada. This resulted in a smooth adoption of oncology biosimilars. As future oncology biosimilars are introduced, this framework will serve as the foundation to educate and train oncology pharmacy staff.

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets

ObjectivesAutomated dispensing cabinets (ADCs) are used in hospitals to improve medication safety and decrease costs. However, ADCs do not completely eliminate the risk of mistakes between look-alike, sound-alike (LASA) medicines....

A systematic literature review of LASA error interventions.

AimsThe aim of this systematic review was to explore and evaluate the efficacy of interventions to reduce the prevalence of look‐alike, sound‐alike (LASA) medication name errors.MethodsWe conducted a systematic review of the literature, searching PubMed, EMBASE, Scopus and Web of Science up to December 2016, and re‐ran the search in February 2020 for later results. We included studies of interventions to reduce LASA errors and included randomized controlled trials, controlled before‐and‐after studies, and interrupted time series. Details were registered in Prospero (ID: CRD42016048198).ResultsWe identified six studies that fulfilled our inclusion criteria. All were conducted in laboratories. Given the diversity in the included studies, we did not conduct a meta‐analysis and instead report the findings narratively. The only intervention explored in RCTs was capitalization of selected letters (“Tall Man”), for which we found limited efficacy and no consensus.ConclusionsTall Man lettering is a marginally effective intervention to reduce LASA errors, with a number of caveats. We suggest that Tall Man gives rise to a “quasi‐placebo effect”, whereby a user derives more benefit from Tall Man lettering if they are aware of its purpose. Keywords: (on scholar one).

An assessment of medication safety practices in selected public health facilities in Kaduna State, Nigeria

Medication errors occur frequently and have significant clinical and financial consequences, which could be preventable. Unsafe medication practices and errors have been found to be amongst the leading cause of injury and avoidable harm in both developed and developing countries. The World Health Organisation (WHO) has recommended implementation of basic solutions to improve medication safety. This study assessed the presence of basic medication safety practices in four (4) public health facilities in Kaduna State, Nigeria. A validated survey tool was adopted which contains sections that assessed practices such as look-alike, sound-alike (LASA) medications, transitions in care, use of information technology, drug information and other practices. A structured interview was conducted with each head of Pharmacy department of the facilities after obtaining their consent. Only one facility had a medication safety committee, none of the facilities had a list of LASA medications nor a list of error proneabbreviations. Only one facility involved pharmacists in obtaining medication histories and none of the facilities uses ‘high risk’ warning label on diluted electrolyte solutions. Basic practices to improve medication safety were not implemented in the facilities. Effort must be put in place for the adoption of medication safety practices. Regulations and policies need to be implemented regarding these practices.
 Keywords: Medication safety; Health facilities; Kaduna State; Nigeria; Medication errors

Interventions to Reduce Problems Related to the Readability and Comprehensibility of Drug Packages and Labels: A Systematic Review.

The aim of the study was to evaluate the effectiveness of interventions designed to reduce problems with readability and comprehensibility in drug labels. A systematic review of observational and experimental studies was conducted using MEDLINE (via PubMed), Embase, and Scopus databases. Two independent reviewers selected articles and collected data about study design, interventions, and outcomes. Of 1786 studies screened, 17 were included in this systematic review. The main findings were described according to the type of intervention in the drug package or label: color-coded labels (7 studies); changes in information layout (5 studies); changes in font size (3 studies); and interventions involving look-alike/sound-alike (LASA) drugs (3 studies). Color changes were important both for healthcare professionals to improve safety in hospital practice and for medication users to differentiate between the types of insulin. Layout changes were effective and included highlighting key information, such as medication name, dose, and instructions. Increased font size yielded good results in the recognition and identification of medications mainly for the population with impaired vision. This review was limited by the heterogeneity of interventions and populations studied, as well as the small number of high-quality studies, which prevented meta-analysis across any one intervention or outcome. All studies reported positive results for the proposed interventions. In the case of LASA drug names, the use of resources beyond Tall Man lettering (such as color and highlighting) reduced recognition errors, which may contribute to the development of new strategies to improve safety in the use of LASA drugs.

Prevention strategies to identify LASA errors: building and sustaining a culture of patient safety

BackgroundPotential look-alike, sound-alike (LASA) errors in outpatient and inpatient prescriptions have been widely described worldwide. However, most strategies of reducing drug name confusion have been only focused on the processes of prescribing and dispensing, often following local rules.Main textAn illustrative recent example about this topic is given: the antidepressant Brintellix® (vortioxetine) (Takeda Pharmaceuticals USA, Inc.) and the antiplatelet medication Brilinta® (ticagrelor) (AstraZeneca LP). Revision of the initiatives that are currently applied to prevent potential LASA errors in different countries around the world and debate about the emerging strategies that could be implemented in short and mid-term. At present, a common policy worldwide on the authorization of unique names for innovative medicines does not exist. The implication of authorities in topdown strategies and the importance of developing an international health policy on the authorization of unique names for innovative medicines are highlighted in the following piece of opinion.ConclusionsBuilding and sustaining a culture of patient safety should be considered as a global top-down strategy which involved all the elements in the system (regulatory bodies, manufacturers and suppliers). The precedent established by the FDA in prevention strategies to identify and avoid LASA errors has been extremely important and should lead to international discussion. Coordinated international efforts are urgently needed in this area for the sake of patients’ safety.

Automated detection of wrong-drug prescribing errors

BackgroundTo assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data.SettingUrban, academic medical centre, comprising a 495-bed hospital and outpatient...

Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases.

Results of a study to estimate the prevalence of look-alike/sound-alike (LASA) medication errors through analysis of Veterans Affairs (VA) administrative data are reported. Veterans with at least 2 filled prescriptions for 1 medication in 20 LASA drug pairs during the period April 2014-March 2015 and no history of use of both medications in the preceding 6 months were identified. First occurrences of potential LASA errors were identified by analyzing dispensing patterns and documented diagnoses. For 7 LASA drug pairs, potential errors were evaluated via chart review to determine if an actual error occurred. Among LASA drug pairs with overlapping indications, the pairs associated with the highest potential-error rates, by percentage of treated patients, were tamsulosin and terazosin (3.05%), glipizide and glyburide (2.91%), extended- and sustained-release formulations of bupropion (1.53%), and metoprolol tartrate and metoprolol succinate (1.48%). Among pairs with distinct indications, the pairs associated with the highest potential-error rates were tramadol and trazodone (2.20%) and bupropion and buspirone (1.31%). For LASA drug pairs found to be associated with actual errors, the estimated error rates were as follows: lamivudine and lamotrigine, 0.003% (95% confidence interval [CI], 0-0.01%); carbamazepine and oxcarbazepine, 0.03% (95% CI, 0-0.09%); and morphine and hydromorphone, 0.02% (95% CI, 0-0.05%). Through the use of administrative databases, potential LASA errors that could be reviewed for an actual error via chart review were identified. While a high rate of potential LASA errors was detected, the number of actual errors identified was low.