* 1. Thank you for taking part in this short 8 question survey. Please note you may complete more than one survey if you are reporting multiple events. Please begin.

Are you a ...

* 2. In what country or geographic location are you presently located/practicing?

* 3. Where did you or your patient experience a Look-Alike Sound-Alike (LASA) Eye or Ear Medication Error/Incident in?

* 4. The LASA Eye or Ear Medication Error/Incident involved the use of ..

* 5. Please list the name(s) of the drug(s) involved (include drug strength, bottle size, and pharmaceutical manufacturer name(s) if possible):

* 6. To the best of your knowledge how would you explain the cause of the Medication Error/Incident. The error was most likely due to (select One):

* 7. Best describe the outcome of the LASA Eye or Ear Medication Error/Incident by selecting one of the choices below.

* 8. Briefly describe the LASA Eye or Ear Medication Error/Incident, the extent of patient harm (if any), and any medical treatment that was provided in a healthcare setting or home.
The AAEECE WPSI to Address LASA Eye an Ear Medication Errors thanks you for your time and assistance in collecting this valuable information that will be utilized to make the use of these products safer for patients and healthcare workers alike. Thank you again.