The National Patient Safety Agency (NPSA) is alerting all healthcare staff involved in the use of intravenous amphotericin of the potentially lethal results if non-lipid and lipid formulations of the drug are confused. These different formulations are used for the treatment of systemic fungal infections. The NPSA is aware of two recent deaths and a number of near misses reported to the National Reporting and Learning System (NRLS) and other similar incidents internationally.

1. Look-alike, sound-alike medication names;
2. patient identification;
3. communication during patient hand-overs;
4. performance of correct procedure at correct body site;
5. control of concentrated electrolyte solutions;
6. assuring medication accuracy at transitions in care;
7. avoiding catheter and tubing misconnections;
8. single use of injection devices; and
9. improved hand hygiene to prevent health care-associated infection.

Press release here.

Dear Healthcare Professional letter