We have reviewed the Japanese literature on patients mistakenly ingesting the plastic press through packages (PTP) together with the tablets or capsules, surveyed the current situation at Kitasato University East Hospital and Kitasato University Hospital (our hospital), and discuss preventive measures.
The literature during the past 10-year period reported about 23.9 cases/year of patients mistakenly ingesting PTP. At our hospital, an average of 5.6 cases were treated annually. When cases not reported in the literature are included, the member may by considerably greater. The reasons for mistaken ingestion include: “took the drug too hastily” “took the drug while talking” and “took the drug mixed with other drug”, suggesting that the patients attention was directed to other factors during the ingestion of the tablets/capsules in many cases.
To prevent the misingestion of PTP, measures are necessary from the drug manufacturer, hospital, and the patient. At Kitasato University East Hospital, an explanatory leaflet for preventing mistaken ingestion of PTP was produced and distributed to patients. After distribution, 75.4% of the patients polled replied that they now realize the danger associated with misingestion and will be more careful from now on. The production and distribution of such explanatory leaflets may by useful for preventing the mistaken ingestion of the PTP by patients.