LOOK-ALIKE SOUND-ALIKE (LASA)-ASSOCIATED HIGH-ALERT MEDICATION ERROR FOLLOWING SELF-MEDICATION RESULTING IN RESPIRATORY PARALYSIS: A CASE REPORT

Abstract

Background: Medication safety is a cornerstone of global healthcare practice and remains essential for preventing avoidable patient harm. Despite continuous advancements in healthcare systems, high-alert medication errors (HAMEs) remain an alarming concern, particularly in the context of self-medication. Such errors can result in life-threatening outcomes, even among skilled healthcare professionals (HCPs) who may inadvertently bypass established safety protocols. Neuromuscular blocking agents (NMBAs) are among the most hazardous high-alert medications because accidental administration can rapidly lead to respiratory paralysis and death if not recognized immediately. Case Presentation: We report a critical incident involving a 34-year-old male operating room (OR) technician who unintentionally self-administered a NMBAs, Atracurium Besylate (Acuron® 50 mg/5 mL), instead of an antibiotic solution. The error occurred when the NMBA was mistakenly used as a diluent for Ceftriaxone 1 g due to visual similarity to sterile water for injection, representing a Look-Alike Sound-Alike (LASA) medication error. Within minutes, the HCP developed apnea, respiratory muscle paralysis, and loss of consciousness, necessitating emergency intubation and mechanical ventilation (MV). Prompt recognition of the event and immediate airway management resulted in complete recovery within hours, with no residual neurological or respiratory complications. Conclusion: This case highlights that even trained HCPs remain vulnerable to HAMEs. Sustainable medication safety requires institutional oversight, adherence to the Ten Rights of Medication Administration, secure storage, clear labeling, and double-check protocols. Special attention must be given to LASA medications to minimize confusion and prevent life-threatening incidents. Additionally, strict prohibition of self-medication is essential to ensure patient and staff safety.