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 randomised 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 capitalisation 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 there 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.