PTPシート誤飲症例の背景解析による誤飲防止策の提案

抄録

In 1997,PTP sheets containing tables were changed so that they could not be separated into individual doses since there had been several cases in which medicines had been swallowed in the PTP.As there are still cases of this happening,we felt the need to clarify the causes and devise a way of preventing them.
Through interviewing 8 patients who had swallowed medicines in the PTP sheet and had them removed at Matsudo City Hospital in last 5 years,the causes of such accidents were being distracted when taking medication and separating medicines into individual doses for convenience.Armed with this knowledge,we questioned a large number of patients visiting community pharmacies on how they kept their medicines at home.Our findings showed that elderly patients and those prescribed multiple drugs tended to separate their medicines,accounting for 45.7% of 368 patients interviewed.There has also been an increase in the number of elderly patients with dementia who have swallowed medicines in the PTP sheet and have not been aware of this until they have had to undergo emergency surgery to remove the PTP when it has caused perforation of the gastrointestinal tract.
To decrease the risk of swallowing the PTP sheet,we propose increasing its size so that patients are physically unable to swallow it,and print a pharmaceutical code and expiration date on each sheet.