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Reporting a Medication Error

Mix-Ups Between Fluticasone Formulations

Published October 26, 2022

Over the past few years, ISMP has received multiple reports of mix-ups involving fluticasone propionate <u>aerosol metered-dose inhalers</U> (Flovent HFA) and fluticasone propionate nasal spray (Flonase). Fluticasone aerosol metered-dose inhalers are indicated for the maintenance treatment of asthma while fluticasone <u>nasal spray</u> is used to temporarily relieve the symptoms of hay fever or other upper respiratory allergies. The nasal spray is available over-the-counter (OTC), but may still be dispensed by the pharmacy. If a person incorrectly receives the nasal spray instead of the metered-dose inhaler, they could miss doses of their asthma maintenance therapy and experience episodes of severe asthma.

In most reports, fluticasone metered-dose inhalers were ordered but the OTC nasal spray product was dispensed. For some of these events, the directions for the metered-dose inhaler (e.g., inhale two puffs into the lungs twice a day) were printed on the pharmacy label that was affixed to the OTC nasal spray product. In another case, the metered-dose inhaler was correctly selected and dispensed but the pharmacy label contained instructions to use the inhaler in the nose. These errors appear to have happened when the pharmacy technician or pharmacist entered the wrong formulation into the computer or selected the wrong product from the shelf.

Here’s what you can do: When picking up medicine from the pharmacy, make sure the medicine is what you expect. If it looks different or the name of the medicine is not what you expect, ask the pharmacist or technician to double check that the medicine is correct. Ask to speak to the pharmacist to learn how to use the medicine. In fact, one of the reports indicated that the error was caught while the pharmacist was explaining how to use the nasal spray when the person was expecting a metered-dose inhaler.

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