Ambulatory Buzz

Information on all things ambulatory from The Joint Commission

Managing High-Alert/Hazardous and Look-Alike-Sound-Alike Medications in Ambulatory Care Settings


This AmBuzz, previously posted in July 2019, addresses the important subject of high alert/hazardous and look-alike sound-alike medications.

High-alert and hazardous medications bear a heightened risk or cause significant patient harm and/or sentinel events when they are used in error and, as a result, require special safeguards.

Look-alike/sound-alike (LASA) medications are those, either written or spoken, which may lead to potentially harmful errors when confused with each other.

In my work as a Joint Commission ambulatory care surveyor, I see so much confusion in a variety of ambulatory settings about “High-Alert/Hazardous”  and “Look-Alike, Sound-Alike” medications (LASA) and how to comply with these critical expectations.  So, I thought I’d share some helpful tips that will help you address this important medication management issue.

Two relevant standards are listed below with some compliance tips:

1. MM 01.01.03 - The organization safely manages high-alert and hazardous medications.

EP 1 The organization identifies, in writing, its high-alert and hazardous medications.
Compliance tips:

  • develop your own list based on unique utilization patterns and internal data about medication errors and sentinel events
  • collaborate with your pharmacy consultant to help develop your list 
  • review National Institute for Occupational Safety and Health (NIOSH) resources to help develop a unique list of high-alert and hazardous medications

EP 2 The organization follows a process for managing high-alert and hazardous medications. 
Compliance tips:

  • segregate medications in different bins or locations
  • distinguish medications by using “tall man lettering ”, i.e. upper case letters
  • sticker identification to identify the high alert or hazardous medications on your organization’s list  

2. MM 01.02.01 - The organization addresses the safe use of look-alike/sound-alike medications. 

EP 1 The organization develops a list of look-alike/sound-alike medications it stores, dispenses, or administers. 

Compliance tips
Your organization needs to develop its own list based on your unique utilization patterns and other internal data about the medication errors and sentinel events. Reminder, your organization needs to ensure your documented list is unique to the medications used within your organization. 

  • work with your pharmacy consultant to help develop your list 
  • The Institute for Safe Medication Practices (ISMP) is a good resource to help your organization develop a unique list of LASA medications.

EP 2 The organization takes action to prevent errors involving the interchange of the medications on its look-alike/sound-alike medications. 

Compliance tips:
Your organization needs to develop a process or strategy to prevent errors with the use of your identified LASA medications that is developed and implemented throughout your organization.  

Common processes or strategies include:

  • segregation of the medications in different bins or locations
  • distinguish medications by using “tall man lettering  ”, i.e. upper case letters
  • sticker identification to identify LASA medications on your organization’s list

EP 3 The organization annually reviews and, as necessary, revises its list of look-alike/sound-alike medications. 
Compliance tips:

  • review your processes to ensure your list of LASA medications is reviewed on an annual basis 
  • ensure you have a process is in place to document the review, and (if applicable), changes, to your list/LASA medications 
  • date stamp the list and/or ensure the information is captured on your annual medication management meeting minutes, which are then reviewed and approved by your governing body                

Additional Compliance Tips
The elements of performance are also applicable to sample medications, if utilized within your organization.
Keep lists available in all areas of your organization where medications on your high-alert/hazardous and LASA medication lists are administered such as:

  • medication rooms
  • crash carts
  • automated dispensers
  • dental carts
  • bulk storage medication cabinets
  • narcotic lockers
  • anesthesia carts
  • block carts
  • anesthesia work rooms
  • treatment rooms
  • immunization rooms 

It’s also essential to account for these areas mentioned above when developing your high-alert/hazardous and LASA medication lists and implementing your  process or strategy to prevent errors. 

Make sure all staff who administer medications within your organization are aware of the organization’s lists, policies, and processes (strategies) to prevent errors when administrating medications that are on your high-alert/hazardous and LASA medication lists. These staff include, but are not limited to:

  • physicians
  • CRNAs
  • registered nurses

Ask questions during staff meetings or in-services about what the staff should do after seeing a medication on your identified lists. 

We want to provide a zero-harm experience with medication administration and it is critical all staff are aware of the risks with high-alert/hazardous and LASA medications.

Bobby J. Hurt MSN, RN, MA is a Joint Commission surveyor and surveys the standards in the Comprehensive Accreditation Manuals for Ambulatory Care and has extensive experience in hospital/ambulatory delivery, administration, and Joint Commission accreditation compliance.