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Reporting a Medication Error

Breathing Easier: Safe Use of Inhaled Medicines

Published February 7, 2024

Respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are often associated with inflammation in the lungs that makes it difficult for the person to breathe. As a result, symptoms such as shortness of breath, coughing, and wheezing can occur. The best way to treat these symptoms is to inhale medicine directly into the lungs using a device called an inhaler. This way the medicine can act faster to relieve these symptoms. If the medicine is taken by mouth as a tablet or capsule, it will take longer for the person to get relief. In addition, the inhaled medicine is often a lower dose than what an oral tablet or capsule would contain. As a result, there may be fewer side effects from inhaled medicines.

There are two basic types of medicines used in inhalers to treat asthma and COPD. One type of medicine is called a bronchodilator. A bronchodilator is a medicine that relaxes the muscles around the airways and increases air flow. Bronchodilators can be short-acting or long-acting. The second type of medicine is a corticosteroid. A corticosteroid is a medicine that reduces inflammation (and mucus) in the airways. Some people may only require treatment with one inhaled medicine. However, others may require more than one type of inhaled medicine at a time. The medicine prescribed will depend on your treatment goals. The goals include the following:

  • Rescue. The treatment goal is to relieve symptoms as soon as they occur. Quick relief or short-acting inhaled medicines (called rescue inhalers) work within minutes after inhalation to quickly open the airways to make breathing easier. The rescue inhaler is only used as needed when symptoms flare. It should not be taken on a regular basis.
  • Maintenance. The treatment goal is to keep breathing difficulties under control and prevent frequent flare-ups. Long-acting inhaled medicines (also called controller inhalers) are typically used once or twice daily, even in the absence of breathing problems. These medicines open the airways and reduce swelling for at least 12 hours. You should never skip a dose of a maintenance inhaler.
  • Rescue and Maintenance. The treatment goals combine the use of both quick relief and controller inhalation medicines to treat these chronic breathing conditions and prevent flare-ups

There are several different devices used to deliver inhaled medicine. The types of inhalers are in the table below:

The American Lung Association provides a detailed chart of inhaled medicines and devices, instructions on how to use a metered-dose inhaler with a valved holding chamber (spacer), and a QR code to access How-To Videos. You can find this resource here.

Errors with inhalers

Since there are so many different types of medicines and devices, mix-ups can occur.  A few examples of errors we received are presented below.

Figure 1. There are five types of Ellipta inhalers.

Product mix-ups with brand name inhaler devices. Some drug companies use the name of the device as part of the brand name of the medicine. An example of this is an inhalation device called Ellipta. The Ellipta inhaler contains powdered medicine. There are five different Ellipta inhalers (Figure 1), each containing a different medicine:

  • Anoro Ellipta (umeclidinium and vilanterol)
  • Arnuity Ellipta (fluticasone furoate)
  • Breo Ellipta (fluticasone furoate and vilanterol)
  • Incruse Ellipta (umeclidinium)
  • Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol)

Each Ellipta inhaler contains combinations of one, two, or three medicines. In 2018, we wrote about mix-ups between the different Ellipta inhalers. These mix-ups continue to occur. We recently heard from a pharmacist who dispensed a Breo Ellipta inhaler instead of a Trelegy Ellipta inhaler. The patient used two doses of the incorrect medicine before recognizing the mistake. The inhaler was returned to the pharmacy, and the correct inhaler was dispensed.

Dosage mix-ups due to similar labeling and packaging. Occasionally, we hear from a pharmacist or consumer that the wrong dose of an inhaler was dispensed.For example, a pharmacist reported that a patient was given the wrong dose of the Dulera inhaler(mometasone furoate and formoterol fumarate dihydrate). Dulera comes in three different doses (50 mcg/5 mcg, 100 mcg/5 mcg, and 200 mcg/5 mcg) (Figure 2).The three packages have similar blue and green colors on their labels. Pharmacists have told us this similarity has led to multiple patients almost receiving the wrong dose. In at least one case, the error was not caught, and a patient received the wrong dose. The patient discovered the error when they got home and returned it to the pharmacy for the correct dose.

Figure 2. Dulera comes in three different dosages. The packaging of each dose looks very similar.

Not understanding how to use the inhaler device. It is important to know how to properly use your inhaler. If not, mistakes can happen. For example, after being discharged from the hospital, a patient was given a prescription for Spiriva HandiHaler (tiotropium bromide), a dry-powder inhaler. The patient was unaware that the medicine capsule needed to be placed into the device so it could be punctured to release the powder and then inhaled. Instead, the patient took the Spiriva HandiHaler (Figure 3) capsules by mouth (swallowed them) for three days. The error was discovered when the patient began having breathing difficulties and was taken to the nearest hospital for emergency care.

Mix-ups between “rescue” and “maintenance” inhalers. Occasionally, mix-ups occur between “rescue” and “maintenance” inhalers. Previously, we wrote about a young child who confused two different inhalers to treat his asthma. While at camp, the boy experienced an asthma attack. His “rescue” and “maintenance” inhalers were both red. He used his “maintenance” inhaler instead of the “rescue” inhaler, in error. The maintenance inhaler contains long-acting medicine that works slowly, so it did not help him. Fortunately, the mistake was noticed quickly, and the child used his rescue inhaler to rapidly ease his breathing.

Figure 3. A patient was unaware the medicine capsule (circled in red) needed to be placed in the Spiriva HandiHaler device.

In recent reports, we heard from a pharmacist who told us a doctor ordered a “maintenance” inhaler with the dosing instructions typically used for a rescue inhaler. Instead of 1 puff (inhalation) per day, the doctor ordered 2 puffs every 4 to 6 hours as needed for shortness of breath. In another case, a pharmacist was reviewing a patient’s medicines when he was admitted to the hospital. The pharmacist told us the patient was incorrectly using his “maintenance” inhaler. The patient told him he was using his inhaler by taking 1 puff, 3 to 4 times a day instead of just 1 puff per day.

Here's what you can do: To help prevent errors with inhaled medicines, consider the following:

Know what type of medicine your doctor has prescribed. Your doctor may prescribe one or more types of inhaled medicine. Be sure you know the name of the medicine, if it is a rescue inhaler or a maintenance inhaler, what the dose is, and how often you need to take it.

Know how to use the device. Be sure you understand how to use your inhaler.

  • At your doctor’s office. Your healthcare provider (doctor, nurse, or pharmacist) should demonstrate how to properly use the device. They should watch you take a dose of medicine to make sure you are using the device correctly.
  • At your pharmacy. When you pick up your prescription from the pharmacy, ask for printed instructions. Companies that make inhalers often provide detailed instructions on how to use their products. You can also ask the pharmacist to demonstrate how to use the device and/or watch you take a dose.
  • At your home. Many companies provide a short video that can be accessed on their website to help visualize the correct technique. The American Lung Association also has a detailed resource page on how to use different devices.

Know when your inhaled medicine expires or cannot be used. Most inhalers have a counter display (dose indicator) to let you know when the inhaler needs to be refilled and when it is empty. Also, some inhalers should only be used for a certain time (i.e., 30 days) after opening. All inhalers have an expiration date and should not be used past that date. Be sure to check the manufacturer’s directions.

Know when your inhaled medicine expires or cannot be used. Most inhalers have a counter display (dose indicator) to let you know when the inhaler needs to be refilled and when it is empty. Also, some inhalers also should only be used for a certain time (i.e., 30 days) after opening. All inhalers have an expiration date and should not be used past that date. Be sure to check the manufacturer’s directions.

Important information about using inhalers with steroids. When using an inhaler that has a corticosteroid, patients should rinse their mouth with water after each dose. Doing this will get the medicine out of your mouth. If inhaled corticosteroids remain in your mouth, it can cause a fungal infection in the mouth known as thrush.

Know how to store your inhaler. To maintain safety, it is important to store your inhaler properly. Below are recommendations on storing your inhaler.

  • ‍Temperature. Do not store your inhaler in your car. Inhaled medicines should not be exposed to extreme heat, cold, or humidity. Doing so may affect the way the medicine works.
  • Safety of children and pets. The medicine in inhalers can be dangerous to children and pets who are accidentally exposed to them. Always store inhaled medicines up and away and out of sight of children. Keep your inhaler away from pets, especially dogs who may chew on them. If your child or pet has been unintentionally exposed to the medicine in an inhaler, call your pediatrician or veterinarian.
  • Store your inhaler with the cap on. Always replace the cap after using your inhaler. Storing an inhaler without a cap, especially in a purse or a pocket, can allow foreign objects to enter the mouthpiece. This can cause choking if the object is accidentally inhaled. Always look inside the mouthpiece for foreign objects before use.

Ask your doctor for an Asthma Action Plan. An Asthma Action Plan is a personal worksheet that outlines actions to prevent asthma symptoms from getting worse and information on when to visit the emergency department or contact your healthcare practitioner. You can visit here to here to download a free Asthma Action Plan.

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