Medication errors remain a major concern in healthcare, with look-alike and sound-alike (LASA) medications contributing to a significant proportion of these incidents. LASA medications can be defined as medications with similar packaging, drug name, appearance, or label. These visual similarities contribute to increasing the risk of medication errors being made. Despite the requirement for two registered nurses to dispense controlled drugs, LASA medications have the potential to create confusion, especially when staff are under time pressure, fatigued or distracted. Confusion between similar-sounding or similar-appearing medicines can lead to incorrect doses or drug administration, with the potential for serious patient harm.
This poster presents local data and practical strategies aimed at reducing LASA-related errors at the Royal Brisbane and Women’s Hospital (RBWH). LASA medications continue to pose a substantial risk to patient safety. In Australian hospitals, 18.7% of reported medication incidents are associated with LASA confusion (Ryan et al., 2025). At the RBWH, 32 Tapentadol–Tramadol errors were reported over a six-month period (April–September 2025), with 81% attributed to LASA confusion. Within the Cancer Care ward, commonly confused medications include Oxynorm and Ordine (look-alike), Tramadol and Tapentadol (sound-alike), and MS Contin and OxyContin (sound-alike). Four Oxynorm–Ordine errors were recorded between 2022 and 2024; however, no further incidents have occurred since the introduction of colour-coded LASA stickers in early 2025 (RBWH Safety & Quality team).
To address this issue, a structured LASA safety initiative was implemented. A key strategy involved placing an “Is this Tramadol or Tapentadol?” reminder card on top of each medication box to prompt staff to double-check and correctly identify high-risk medicines. In addition, colour-coded stickers were applied to Oxynorm and Ordine bottles and matched to the medication book to enhance visual differentiation and reduce confusion during preparation and administration. These interventions reinforce the importance of adhering to medication safety standards, including the six rights of medication administration (right patient, medication, dose, route, time, and documentation), reading labels twice, and completing an independent two-nurse check for high-risk medicines. This poster was recognised as the winner of the 2025 Metro North Medication Safety Awareness Poster Competition, reflecting its innovation, practical applicability, and contribution to improving medication safety within the organisation.
Overall, this poster aims to increase awareness of the high rate of medication errors associated with LASA medications and recommend strategies to implement in order to reduce this risk. The evident decrease in medication errors following the implementation of this initiative at the RBWH Cancer Care ward is clearly demonstrated, highlighting the importance of medication safety and awareness.