medication errors involving these drug combinations. Proactive assessment of potential for LASA medication errors should evaluate for potential look-alike packaging problems in addition to the drug names (McCoy, 2005). Furthermore, organizations could develop and implement process enhancements, including moving and reorganizing shelf storage bins, improving labeling for intravenous medications or other dosage forms with similar packaging, revising processes for selecting and maintaining the list of LASA medications to include real-time review of new medications added to the formulary and changes in packaging resulting from contract changes or drug storage.