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[No Blister-Wrapped Pills: Perforation after Ingestion a Blister-Pack]
A Prokop1, H Stepper2, S Koll3
1Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Kliniken Sindelfingen, Klinikverbund Südwest.
Zeitschrift Fur Orthopadie Und Unfallchirurgie
|June 29, 2016
Summary
Accidentally swallowing blister packs can cause severe gastrointestinal perforations. A hospital policy change banning bedside blister pack dispensing eliminated further cases, improving patient safety.
Area of Science:
- Gastroenterology
- Surgical Safety
- Patient Harm Prevention
Background:
- Blister packaging of medications presents a risk of accidental ingestion.
- Swallowed blister packs can lead to severe gastrointestinal perforations, mediastinitis, or peritonitis.
- These complications are associated with high mortality rates.
Observation:
- Two cases of cognitively limited patients with perforations from swallowed blister packs were observed.
- One case involved esophageal perforation, and the other involved ileal perforation.
Findings:
- The patient with esophageal perforation died from multi-organ failure despite surgical intervention.
- The patient with ileal perforation survived sepsis following multiple surgical procedures.
Implications:
- Implementing a hospital-wide policy to prohibit bedside dispensing of blister-packed medications can prevent such injuries.
- This policy change has demonstrated effectiveness in preventing further cases of perforation.
- Healthcare facilities should review medication packaging and dispensing practices to enhance patient safety.
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