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CASE STUDY

Group 3

Prepared by: Anero, Jefher Ian


Luminog, Junjie
Mendoza, Marjorie
A patient was prescribed Lasix
20mg tablet, but was dispense
Losec 20mg.
WHAT IS THE PROBLEM?

The patient was prescribed a diuretic drug for


congestive heart failure causing edema which is
the Lasix, but it was dispensed an antacid drug of
which a proton-pump inhibitor which is Losec.
CAUSE OF THE PROBLEM:
Lasix and Losec drugs are belong to the SALAD group, which is Sound-alike
Look-alike drugs. The cause of the problem is maybe the misinterpretation of
the pharmacy in charge and the arrangement of the drug in the pharmacy.
Maybe the pharmacist receive the prescription and read it without double
checking, so he/she thought that the prescribed medicine is losec and not Lasix.
And maybe the pharmacist interpret the prescription correctly, but when he/she
get the medicine in the shelf, he/she picks up Losec instead of Lasix maybe its
because the two drugs are put together in one shelf in which it must be
separated.
EFFECTS OF THE PROBLEM:

Lasix?
Lasix (furosemide) is a loop diuretic (water pill) that prevents your body from absorbing too much
salt. This allows the salt to instead be passed in your urine.
Lasix is used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a
kidney disorder such as nephrotic syndrome.
Lasix is also used to treat high blood pressure (hypertension).
Losec?
is a medication used in the treatment of gastroesophageal reflux disease, peptic ulcer disease,
and ZollingerEllison syndrome. It is also used to prevent upper gastrointestinal bleeding in people
who are at high risk.
is a proton-pump inhibitor and as such blocks the release of stomach acid.
If the patient who received Losec, will accidentally take
that drug, it may put his/her life into danger because,
losec is a proton-pump inhibitor which is an indigestion
drug that raise the risk of having a heart attack of which
the patient trying to treat it with Lasix, which is a diuretic
used to treat fluid retention (Edema) in patient with
congestive heart failure.
SOLUTION TO THE PROBLEM:
SALAD drugs are the most confusing set of drug of which they are Sound alike-Look alike drugs and often result on error in
providing medication. As a pharmacist we must be always bear in our mind that our profession is dealing with life of which
mental attentive is much needed.
To avoid any problem with regards to SALAD drugs, pharmacist must be:
Listing both the brand and generic names on medication records.
Storing products with look-alike or sound-alike names in different locations.
Employing double checks in the distribution process.
Affixing name alert stickers to areas where look-alike or sound-alike products are stored.
Changing the appearance of look-alike product names on pharmacy labels, computer screens, shelf labels and bins, and
medication records by highlighting, through bold face, color, and/or tall man letters, the parts of the names that are
different (e.g. hydrOXYzine, hydrALAzine).
Having physicians write prescriptions using both the brand and generic names.
Alerting consumers to the potential for mix-ups.
Encouraging patients and direct care staff to question pharmacists and nurses about medications that are unfamiliar or
look or sound different than expected.