CPS Safety Alert/Watch – Look Alike Sound Alike Medications

August 10, 2018    |   By: Aimee Terrell


  • Kenalog 40 mg/1 ml single dose vial (contents 1 ml)
  • Kenalog 200 mg/5 ml multi-dose vial (contents 5 ml; concentration 40 mg/1 ml)

Actionable Items to Mitigate Risk:

  • Remain consistent with ordering practices. If it is your organization’s practice to routinely order single dose vials, continue ordering single dose vials. Do not switch from ordering single dose to multi-dose without appropriate communication across your organization.
  • Store multi-dose vials in different locations from where single dose vials are stored.
  • Evaluate

The Culture Connection:

  • Encourage staff to speak up and report similarities of medication and also any incidents, near misses or unsafe conditions pertaining to look alike sound alike medication.
  • Encourage staff to use two person check of medication prior to administration.
  • Leadership should evaluate the culture of their organization to ensure staff feel safe reporting incidents involving look alike sound alike medications.



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