The Problem with Amphotericin.

Area of Science:

• Pharmacology
• Patient Safety
• Drug Formulation

Background:

• Inadvertent administration of amphotericin B (Fungizone™) instead of liposomal amphotericin (AmBisome®) has led to patient harm and safety alerts.
• Current safety recommendations focus on organizational strategies, neglecting product-specific design factors.

Purpose of the Study:

• To highlight the risks associated with similar presentations of intravenous amphotericin formulations.
• To advocate for consideration of product design as a factor in medication errors.

Main Methods:

• Literature review of reported patient harm incidents.
• Analysis of existing patient safety recommendations.
• Comparison of amphotericin B (Fungizone™) and liposomal amphotericin (AmBisome®) product characteristics.

Main Results:

• Both AmBisome® and Fungizone™ are supplied in 50 mg vials, despite differing dose recommendations, increasing confusion.
• The need for multiple AmBisome® vials for adult infusions deviates from standard practice, elevating error risk.
• Existing safety measures do not address inherent product similarities that contribute to errors.

Conclusions:

• Product design, specifically the similarity between AmBisome® and Fungizone™ presentations, is a significant, unaddressed factor in medication errors.
• Manufacturers and regulatory authorities must consider product design in mitigating risks associated with intravenous amphotericin administration.
• External factors, including medicine design, should be identified and addressed to prevent patient harm.