The National Patient Safety Agency has announced urgent guidance alerting healthcare staff to the potential risk of confusion between different formulations of intravenous amphotericin, used to treat serious fungal infections.
Intravenous amphotericin is available in two formulations - lipid and non-lipid - which have different dose recommendations. Confusion between the two formulations can lead to over or under doses which can have potentially fatal side effects or result in sub-therapeutic treatment.
Two recent deaths involving confusion when administering amphotericin have been reported to the agency, along with a number of “near misses”.
It recommends that all NHS and independent sector organisations in England and Wales carry out an immediate risk assessment of amphotericin products and procedures, and that managers should communicate the potential risks related to amphotericin to their staff.
