By Dr Kamal ‘Akl, Consultant Paediatrician & Paediatric Nephrologist
After visiting the doctor, Rana takes her child to a nearby pharmacy to fill the prescription. To her surprise, the pharmacist struggls to read the doctor’s handwriting. Fifteen minutes pass as the pharmacist attempts to decipher the text, but without success.
Just then, a doctor walks in and offers to help. Grateful for his assistance, the mother and pharmacist hand him the prescription. However, the doctor quickly realises that neither the medication name nor the diagnosis is clearly written.
Doctor: What is the medicine for?
Mother: A scalp infection
Doctor: The prescribed medication is griseofulvin, typically used for fungal scalp infections resistant to topical antifungal treatments
Pharmacist: Thank you so much!
Look-Alike Medication
Medication errors are more common than many realise and can harm patients in unexpected ways.
Illegible handwriting is a frequent cause of confusion, but another major issue is look-alike, sound-alike (LASA) medications.
Many drugs have similar names, leading to mix-ups—especially in a busy pharmacy. Patients can end up with the wrong medication, and the error may only be discovered when side effects appear
For example, a doctor once prescribed medication for a child with a urinary bladder condition. However, due to a LASA mix-up, the pharmacist dispensed the wrong drug. The mother later contacted the doctor, concerned that her child was constantly fatigued.
Upon review, the doctor realised that the child had been given a blood pressure-lowering medication instead.
One study identified over 3,500 LASA cases affecting children alone. Children and the elderly are particularly vulnerable to adverse drug effects, making such errors even more dangerous.
LASA drug confusion
Some antihypertensive (blood pressure) medications sound like antidepressants
Labetalol, used for high blood pressure, may be mistaken for albuterol, an asthma medication
The diuretic furosemide can be confused with fosinopril, an antihypertensive drug.
Some common antibiotics have names similar to veterinary medications prescribed for pets
LASA drugs account for 25 percent of medication errors, often due to packaging similarities and name confusion. Even medications with the same brand name but different dosages can pose risks.
Preventing medication errors
Preventing these errors requires collaboration amongst doctors, pharmacists and patients:
Doctors
Write prescriptions clearly and legibly
Include both generic and brand names of medications
Specify the diagnosis or indication for use
Be aware of LASA drug risks and limit telephone orders when possible
Pharmacists
Ensure the correct medication and dosage are dispensed
Store LASA medications separately (in yellow bins with TALL MAN lettering and warning labels)
Read labels carefully instead of relying solely on visual recognition
Double-check high-risk and dangerous drugs with a second or even third person before dispensing
Patients and parents
Verify with the pharmacist that the correct medication has been provided before leaving the pharmacy
Be aware that medications with the same generic name may have different brand names—and some may not work as effectively for them
Ask their doctor if a specific brand is preferred or should be avoided.
By taking these precautions, we can significantly reduce medication errors and ensure safer healthcare for all.
