A 59-year-old man was mistakenly prescribed Slow-Na instead of Slow-K due to incorrect selection from a drop-down list in the prescribing software. This error was identified by a pharmacist during a home medicine review (HMR) before the patient began taking the supplement. The reported error emphasizes the need for vigilance due to the emergence of novel look-alike, sound-alike (LASA) drug pairings. This case highlights the important role of pharmacists in medication safety.
NAUNTON, M., KYLE, G., & GARDINER, H. (2015). Look-alike, sound-alike medication errors: A novel case concerning a Slow-Na, Slow-K prescribing error. International Medical Case Reports Journal, 8(2), 51-53. https://doi.org/10.2147/IMCRJ.S78637