Using the National Poison Data System to Detect Mistaken Oral Ingestions of Medication Capsules Designed for Use in Pulmonary Inhalers

摘要

Introduction: In 2006, the Institute of Medicine proposed initiatives to decrease medication errors using hospital monitoring systems for adverse event (AE) surveillance. Serendipitously, several poison center clinicians noticed a trend of inadvertent oral ingestions involving formoterol fu-marate and tiotropium bromide. Each product is packaged in capsules for insertion into special pulmonary inhaler devices for chronic pulmonary disease. The National Poison Data System (NPDS) is a near real-time data and surveillance system capable of tracking AEs. Our objective was to assess the feasibility of NPDS to analyze outpatient AEs, employing formoterol and tiotropium ingestions as a model.Methods: Retrospective review of NPDS data for formoterol and tiotropium mistaken oral ingestions (MOI) (2001-2007). Inclusion criteria were age over 6 years, exposures, all administration routes, all reasons, incorrect dosing route, and all medical outcomes. Primary outcome measures were number of MOI cases and demographics of at-risk patients.Results: There were 3,919 formoterol and 18,096 tiotropium cases that met inclusion criteria. MOI cases with minor or moderate outcomes were formoterol 82 (2.2%) and tiotropium 131 (0.8%). Neither drug had a major medical outcome or death. Mean age and gender were similar for both medications. MOI was more common among female patients. Health care facility MOIs accounted for 19 (0.5%) formoterol and 35 (0.2%) tiotropium cases. From 2005 to 2007, formoterol and tiotropium cases accounted for 35% to 45% of all NPDS-tracked AEs.Conclusion: NPDS data analysis revealed the magnitude of AEs for capsule-shaped medications for inhaler use was more common than previously identified.