Error in LASA medication administration during anesthesia. Case report

Hernán Szmulewicz; Charo Martínez; Guadalupe Saco; Diego Toscana

doi:10.5554/22562087.e1148

Hernán Szmulewicz Department of Anesthesiology, British Hospital of Buenos Aires. Buenos Aires, Argentina. https://orcid.org/0000-0002-3741-3955
Charo Martínez Department of Anesthesiology, British Hospital of Buenos Aires. Buenos Aires, Argentina.
Guadalupe Saco Department of Anesthesiology, British Hospital of Buenos Aires. Buenos Aires, Argentina.
Diego Toscana Department of Anesthesiology, British Hospital of Buenos Aires. Buenos Aires, Argentina.

DOI: https://doi.org/10.5554/22562087.e1148

Keywords: Medication errors, Patient safety, Anesthesia, LASA medications, Safety standards

Abstract References How to Cite Downloads

Abstract

Anesthetic practice involves the use of multiple drugs administered via various routes. Medication administration errors are frequent and represent one of the leading causes of adverse events. The incidence of errors in anesthesia is estimated to range between 0.02% and 1.12%. This case is particularly relevant as it illustrates how the similarity in ampoule appearance can lead to errors, emphasizing the potential risks in anesthetic practice and the need for vigilance. The article discusses the case of a 45-year-old male undergoing elective cholecystectomy. Due to the similarity of ampoule appearances, the anesthesiologist mistakenly administered the wrong medication, fortunately without clinical consequences. Neuromuscular monitoring confirmed the absence of residual effects. Look-Alike Sound-Alike (LASA) medications increase the risk of errors. Factors such as inexperience and time pressure significantly contribute to these events. Implementing preventive measures and strict regulations is essential to mitigate risks. This case highlights the impact of LASA medications in anesthesia and the importance of implementing preventive measures and stringent regulations to minimize such errors. Likewise, it emphasizes the need to adopt enhanced safety protocols and to standardize the ampoules according to international standards. Contributing to improving patient safety during anesthesia requires a systematic approach to identify risks and mitigate the consequences of LASA medications-associated errors.

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How to Cite

1.

Szmulewicz H, Martínez C, Saco G, Toscana D. Error in LASA medication administration during anesthesia. Case report. Colomb. J. Anesthesiol. [Internet]. 2025 May 20 [cited 2025 Dec. 13];54(1). Available from: https://www.revcolanest.com.co/index.php/rca/article/view/1148