Look Alike Sound Alike LASA Error

Raising awareness of recent errors regarding promazine (antipsychotic)

There have been several incidents locally where promazine has inadvertently been prescribed instead of the intended promethazine.

Promazine is a first-generation (typical) antipsychotic, licensed for agitation and is  rarely used. Conversely, promethazine is a sedating antihistamine, licensed for treatment of allergic symptoms, sedation (short term only) and as an antiemetic.

These two medications are “look alike- sound alike” (LASA) medications, and their similarities may be compounded by additional factors such as similar packaging, tablet appearance and tablet strength (25mg) as well as their sedating properties.

Alerts are being added to GP clinical systems to raise awareness of name similarities at the point of “picking” the medication, when prescribing.

Action for Community Pharmacy when dispensing:

• If you see promazine prescribed for the first time, please confirm with the patient what they are expecting. If in doubt, contact the prescriber.
• If possible, identify the two products as LASA and separate them in the drawer/ on the shelf.