Error en la administración de medicamentos LASA durante la anestesia. Reporte de caso.

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Bibliographic Details
Title:	Error en la administración de medicamentos LASA durante la anestesia. Reporte de caso.
Alternate Title:	Error in LASA medication administration during anesthesia. Case report.
Authors:	Szmulewicz, Hernán¹ nan_Szmulewicz@hotmail.com, Martínez, Charo¹, Saco, Guadalupe¹, Toscana, Diego¹
Source:	Colombian Journal of Anesthesiology / Revista Colombiana de Anestesiología. Jan-Mar2026, Vol. 54 Issue 1, p1-5. 5p.
Subjects:	MEDICATION errors, MEDICATION safety, ANESTHESIA, NEUROMUSCULAR transmission, PATIENT safety, PRECAUTIONARY principle
Abstract (English):	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. [ABSTRACT FROM AUTHOR]
Abstract (Spanish):	La práctica anestésica implica el uso de múltiples medicamentos administrados por diversas vías. Los errores en la administración de medicamentos son frecuentes y representan una de las principales causas de eventos adversos. Se estima que la incidencia de errores en anestesia varía entre el 0,02 % y el 1,12 %. Este caso es particularmente relevante, ya que ilustra cómo la similitud en la apariencia de las ampollas puede llevar a errores, enfatizando los riesgos potenciales en la práctica anestésica y la necesidad de vigilancia. En el artículo se discute el caso de un hombre de 45 años de edad sometido a una colecistectomía electiva. Debido a la similitud en la apariencia de las ampollas, el anestesiólogo administró por error el medicamento equivocado; afortunadamente, sin consecuencias clínicas. El monitoreo neuromuscular confirmó la ausencia de efectos residuales. Los medicamentos de apariencia y sonido similar (LASA, por las iniciales en inglés de look alike, sound alike) aumentan el riesgo de errores. Factores como la inexperiencia y la presión de tiempo contribuyen significativamente a estos eventos. Este caso destaca el impacto de los medicamentos LASA en la anestesia y la importancia de implementar medidas preventivas y regulaciones estrictas para minimizar tales errores. Asimismo, enfatiza la necesidad de adoptar protocolos de seguridad mejorados y estandarizar las ampollas según normas internacionales. Contribuir a mejorar la seguridad del paciente durante la anestesia requiere un enfoque sistemático para identificar riesgos y mitigar las consecuencias de los errores asociados a medicamentos LASA. [ABSTRACT FROM AUTHOR]
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Database:	MedicLatina

Description
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. [ABSTRACT FROM AUTHOR]
ISSN:	01203347
DOI:	10.5554/22562087.e1148