NPSA issues alert on injectable amphotericin preparations
Confusion between the two forms of injectable amphotericin has led to a safety
alert being issued to health care staff following two recent deaths.
The National Patient Safety Agency has issued the alert warning of potentially
lethal results if non-lipid formulations and lipid formulations of the
drug are confused. It says that the NHS and independent health care sector
in England and Wales should undertake an immediate risk assessment of
amphotericin products and procedures, and ensure that all staff involved
in prescribing, preparation, supply and administration of the drug are
aware of the risks.
Linda Matthew, senior pharmacist at the NPSA, commented: “We expect
the communication process to be led by chief pharmacists. The risk assessment
is a collaborative process between pharmacy, nursing and medical personnel,
but we fully expect it to be co-ordinated by the chief pharmacists.”
To reduce risks the NPSA says that both the complete generic name and
proprietary name should be used when prescribing and dispensing the products,
and that ideally the products should only be dispensed and prepared in
the pharmacy department.
Well-differentiated or separate storage spaces
should be considered in the pharmacy, in addition to cautionary labels
to remind staff about the differences between the products.
The recent deaths resulted from patients being prescribed and given
the non-lipid formulation of amphotericin, but the dose being calculated
based on the lipid formulation. |
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