一起因包装相似导致用药错误的病例报告：不安全系统的典型替代指标。
Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.
作者信息
Schnoor Joerg, Rogalski Christina, Frontini Roberto, Engelmann Nils, Heyde Christoph-Eckhardt
机构信息
Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
Office of Quality and Risk Management, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
出版信息
Patient Saf Surg. 2015 Mar 13;9:12. doi: 10.1186/s13037-014-0047-0. eCollection 2015.
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.
CASE PRESENTATION
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.
背景
首字母缩写词LASA（外观相似、发音相似）指的是意外混淆外观相似和/或发音相似药物的问题。危及患者安全的用药错误最常见的原因是LASA以及工作量大。
病例介绍
一份关于因包装相似导致术后镇痛阿片类药物用药错误的严重事件报告突出了日常场景中的LASA问题。改用通用品牌的药物每年可节省高达16%的成本。因此，由于新引入的通用阿片类药物外观相似，发生了用药混淆事件。由于连续用药不足，这次基于LASA的用药错误未引发危及生命的情况。
结论
目前预防LASA的建议相当广泛；然而，在按病例支付一次性费用的系统中，并非所有这些安全措施都可行。这个问题仍需根据具体情况，考虑当地情况和财务问题来解决。
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