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Look Alike Due to Change in Product

June 11 , 2018

Issue:

Atasol-30® (acetaminophen 325 mg – caffeine 15 mg – codeine 30 mg) in control pack format and 500 tablet bottle is no longer available due to discontinuation by manufacturer.

The new product will be ratio-Lenoltec No. 3 (acetaminophen 300 mg – caffeine 15 mg – codeine 30 mg).

There is a potential for look-alike issue between ratio-Lenoltec No. 3 and ratio-Oxycocet (acetaminophen 325 mg – oxycodone 5 mg)2018-06-06 ratio lenoltec  2018-06-06 Ratio Oxycocet

Actions:

  • Review site inventory to determine local applicability of this look-alike risk
  • Check storage areas to ensure the correct medications are stocked in their
  • respective containers/bins.
  • Consider modifying processes (e.g. read the name of the medication out loud when
  • selecting or restocking the product).
  • Consider implementation of one or more safety strategies, if applicable.

Recommended Safety Strategies to Mitigate Look-Alike Risks:

  • Ensure medication storage areas are orderly, segregated and clearly labeled.
  • Separate the two look-alike products. This could be achieved by placing an empty bin between products on the storage shelf.
  • Move one of the medications to a new/different location. Use signage to redirect staff if appropriate.
  • Label the look-alike products and/or storage areas with auxiliary warning labels.
  • Consider local communication of identified risk to clinical program/site/zone if applicable (notifications via email or newsletters, highlighting in safety huddles, etc).

Contact Information:
Please contact your site pharmacy department with any questions or concerns.

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