CPS Safety Alert/Watch – Look Alike Sound Alike Medications

August 10, 2018    |   By: Aimee Terrell

Medication:

  • 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.

Resources:

BLOG:

Are Paramedics Ignoring Hand Hygiene?:

“Many paramedics ignore hand hygiene rules, study finds” A new study looked at hand hygiene practices of paramedics from Finland, Sweden, Denmark and Australia.  The study was featured in Health Daily

CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators:

BACKGROUND: Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator. Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to expe

The #1 topic they didn’t teach you in Paramedic School: Culture:

I have been working with the Center for Patient Safety (CPS) for about four months, and I’m learning something new every day.  As a Paramedic, patient safety has always been a high priority, but I didn

Read More

RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.