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ALERT: mix-ups between conventional and lipid formulations of amphotericin B can be extremely dangerous

Christine Koczmara1, Heather Richardson, Sylvia Hyland

  • 1Institute for Safe Medication Practices Canada. ckoczmara@ismp-canada.org

Dynamics (Pembroke, Ont.)
|April 8, 2011
PubMed

Insights

Healthcare providers must be aware of Amphotericin B formulation errors. Incident reports show harm from mix-ups between conventional and lipid formulations, necessitating improved safety strategies.

Area of Science:

  • Pharmacology and Therapeutics
  • Patient Safety
  • Drug Administration

Background:

  • Amphotericin B, a critical antifungal, has conventional and lipid formulations.
  • Despite newer agents, Amphotericin B remains in use, posing potential risks.
  • Incident reports highlight medication safety concerns with Amphotericin B.

Purpose of the Study:

  • To review reported incidents of Amphotericin B mix-ups.
  • To identify patient harm resulting from formulation errors.
  • To emphasize the need for enhanced safety strategies in Amphotericin B administration.

Main Methods:

  • Analysis of incident reports submitted to ISMP Canada.
  • Focus on cases involving confusion between Amphotericin B formulations.
  • Review of patient harm associated with medication errors.

Main Results:

  • Significant patient harm reported due to mix-ups between conventional and lipid Amphotericin B formulations.
  • Incident reports indicate a continued risk of error.
  • Errors stem from confusion regarding different Amphotericin B drug products.

Conclusions:

  • Practitioners require alerts regarding Amphotericin B formulation differences.
  • System-level safety strategies are crucial to prevent medication errors.
  • Minimizing harm necessitates vigilance in prescribing and dispensing Amphotericin B.

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