SUPERINTENDENT FOCUS


TACKLING LOOK ALIKE, SOUND ALIKE ERRORS


It deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. By Mike Embrey, Right Medicine Pharmacy


T


he rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is


bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.


Chances are you read that without much difficulty. It is a simple but powerful reminder of how the brain works. We rarely process every single letter. Instead, we recognise patterns and fill in gaps automatically. In most situations, this makes us faster and more efficient. In a busy community pharmacy, however, that same shortcut can become a patient safety risk.


Community pharmacy rarely slows down. Prescription volumes continue to rise, new services are introduced and patients rely more heavily than ever on their local pharmacy team. In that environment, safety must remain the constant priority.


One of the most persistent and well documented risks is Look Alike Sound Alike medicines. These are drugs with similar spelling, pronunciation or packaging.


When workload is high and interruptions are frequent, it becomes easier to glance at a label rather than read it fully. That is when our natural tendency to skim can lead to near misses or dispensing errors.


Several factors increase the likelihood of LASA incidents: High workload, fatigue and frequent interruptions - Busy dispensaries, staffing pressures and constant workflow demands can lead to cognitive overload. Under pressure, staff may unintentionally skim labels or rely on visual recognition rather than careful reading.


Similar packaging, branding or colour schemes - Medicines that share comparable box designs, font styles or colour palettes increase the risk of visual confusion, particularly when products are stored close together.


Storage of similar products side by side - Keeping medicines with similar names or strengths adjacent on shelves increases the likelihood of selection error, especially during peak dispensing periods.


Ongoing risks associated with handwritten prescriptions - Although electronic prescribing has reduced risk, handwritten prescriptions can still introduce ambiguity, particularly where drug names appear similar.


Reducing the risk requires action at every level. Manufacturers can contribute by designing packaging that clearly differentiates products and by adopting “Tall Man” lettering, such as HydrOXYzine and HydrALAZINE, to highlight critical differences between similar names.


Within the pharmacy, practical safeguards remain essential: Separate high risk products and use clear visual alerts - Physically separating known LASA pairs and using shelf markers or warning labels can prompt staff to pause and verify selection before dispensing.


Mandate full name reading within SOPs and ensure robust double checking - Standard Operating Procedures should require staff to read the entire medicine name and strength aloud during key stages of the dispensing process, with independent double checks embedded into workflow.


Maintain a tidy, organised dispensary environment- Clear benches, structured basket systems and logical shelf layout reduce distraction and help prevent mix ups between patients and medicines.


Share learning from near misses openly within the team - Regular safety discussions raise awareness of recurring LASA pairs and encourage a culture where staff feel confident reporting and reflecting on errors.


Use patient counselling as a final safety check - Showing the medicine to the patient and confirming name, dose and indication provides an important final opportunity to detect discrepancies before supply.


Technology, including barcode scanning and dispensing automation, provides an additional and highly effective layer of protection.


Our brains are wired for efficiency. Strong systems ensure that efficiency enhances care rather than undermines it.


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OUR NATURAL TENDENCY TO SKIM CAN LEAD TO NEAR MISSES OR DISPENSING ERRORS


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