A systematic literature review of LASA error interventions.

AIMS: The aim of this systematic review was to explore and evaluate the efficacy of interventions to reduce the prevalence of look-alike, sound-alike (LASA) medication name errors. METHODS: We conducted a systematic review of the literature, searching PubMed, EMBASE, Scopus and Web of Science up to December 2016, and re-ran the search in February 2020 for later results. We included studies of interventions to reduce LASA errors and included randomized controlled trials, controlled before-and-after studies, and interrupted time series. Details were registered in Prospero (ID: CRD42016048198). RESULTS: We identified six studies that fulfilled our inclusion criteria. All were conducted in laboratories. Given the diversity in the included studies, we did not conduct a meta-analysis and instead report the findings narratively. The only intervention explored in RCTs was capitalization of selected letters ("Tall Man"), for which we found limited efficacy and no consensus. CONCLUSIONS: Tall Man lettering is a marginally effective intervention to reduce LASA errors, with a number of caveats. We suggest that Tall Man gives rise to a "quasi-placebo effect", whereby a user derives more benefit from Tall Man lettering if they are aware of its purpose.

'Red as a beet and blind as a bat' Anticholinergic delirium in adolescents: lessons for the paediatrician.

Anticholinergic syndrome has been widely documented in the literature but is uncommon in paediatric medicine. Teenage boys are most at risk of self-induced anticholinergic syndrome through intentional ingestion of plants. We report on a 14 year old boy who presented to our hospital with clinical signs of anticholinergic toxicity and who was discharged 36 hours after admission with no major residual effects. Classical anticholinergic syndrome should be readily diagnosed by the experienced clinician ('hot as a hare, red as a beet, dry as a bone, blind as a bat and mad as a hatter'). Acute presentations should be treated with benzodiazepines and supportive care. Treatment of the delirium with haloperidol may be harmful. Lack of familiarity with anticholinergic syndrome may also delay the diagnosis or result in potentially harmful treatments. A high index of suspicion is often required in the paediatric setting due to infrequent acute hospital presentation.