Preventing Patient Deaths from Fentanyl Patches

A recent report from the Institute for Safe Medication Practices warns about the dangers of misprescribing fentanyl transdermal patches, such as Duragesic. ISMP reminds practitioners that these patches are intended only for patients who are opioid-tolerant, and should not be used for acute pain.

ISMP also pointed out other prescribing errors. In some cases, deaths occurred in patients who were prescribed multiple fentanyl patches, resulting in overdose. In other cases the fentanyl was prescribed in addition to other pain medications, such as oxycodone, or it was prescribed for patients with pre-existing respiratory compromise. ISMP points out that sometimes pharmacists have dispensed these prescriptions without questioning them, and nurses have applied the patches without recognizing the prescribing error.

Here are some of ISMP's recommendations to help avoid these tragic and preventable errors:

• Prescribe fentanyl patches only for patients who are opioid tolerant, and who have chronic pain that is not well-controlled with shorter-acting analgesics. These patches should not be used for postoperative pain, or for pain that's short-term or intermittent. Pharmacists should ensure that the patient is opioid-tolerant and suffering from chronic pain before dispensing the drug, and should question the prescriber if this is not the case.

• Set dosing limits. For example, pharmacy computer systems could be set to flash an alert if more than 25 mcg per hour has been prescribed as a first-time dose. Also, in evaluating whether the dose is appropriate, take into account other opiates or analgesics that may have been prescribed.

• Educate practitioners and patients to know the signs of overdose, which include respiratory distress, shallow breathing, fatigue, sleepiness, confusion, dizziness and fainting.

• Prescribing errors are not the only cause of deaths and injuries from fentanyl patches. They also occur when patients mis-use the patches. Sometimes patients and family members do not understand that heat can increase absorption of the drug to dangerous levels. So patients should be told to avoid heating pads, electric blankets or hot baths while the patch is in place, and let their doctors know if they develop a temperature above 102 degrees.

• There have also been cases where children found used patches in the trash and applied them to their own bodies, and died as a result. And so patients should be warned to dispose of the patches by folding them in half and flushing them down the toilet.




FDA Patient Safety News: September 2007

For more information, please see our website:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=67#3

Category:

News & Politics

Tags:

• Duragesic
• fentanyl
• overdose
• medication
• error
• FDA
• Patient
• Safety
• News

[jozsefkacsa]

I know ppl selling their patches to Opiate addicts and some of them scrape the jelly off the pach mix itwitha little water and shoot it up I used to do it a 100 micro gramm patch u get like 5-6 fixes.I blacked out few times lucky still alive

[AMASSEY1000]

My son's father died of fentanyl toxicity in May 2011. His doctor also prescribed morphine with it. He was alone when he passed. He was a recovering addict with a medical disability living in a travel trailer trying to do the best he could. I believe his doctor and and drug industry failed him.

[animegirl101able]

i been on fentanyl patch before and it made me sick as a dog for 3 to 4 days nothing but my face in the tolite throwing up

[ScrewTheLiving]

@tampabayismyhome That's terrible, I'm sorry. The doctor actually rx'd fent for the first time to a non-opiate tolerate patient? I'm not usually for suing doctors for this type of thing.. but..

[mdsmemories]

My vet said the patch is really designed for human skin & they aren't even sure how much of it actually gets absorbed into an animal's skin. He also said a lot of vets use the patch on animals that have just had surgery, etc. So, then if they don't even know if its effective & it's really designed for humans, then why in the hell are so many vets using it on animals? Are the vets all getting some kind of kickback from the drug company who makes it or what???

[tampabayismyhome]

@mdsmemories With fentanyl you have to be on opiates before you can take the patch otherwise you will overdose and die. One of my friends thought it would be a good idea to chew on one of the patches and ended up dying a few hours later that was 4 months ago. And his family sued the doctor and were awarded something like $750.000 maybe you have a lawsuit to.

[mdsmemories]

@tampabayismyhome No he did not get any chemo, but the vet claimed if he got some pain relief then he might get his appetite back. After the cat died he tried to claim "Well we could tell he probably didn't have that much longer to live anyway." And I was like really? Why didn't you just say so in the first place & I wouldn't have bothered with the stupid patch! They did shave a spot on his shoulder for the patch, which they also stapled to his skin! The whole thing just made me mad.

[mdsmemories]

Fentanyl is being overused in PETS also. My stupid vet recommended a Fentanyl patch for my cat who had cancer, about a day later, he died. After I removed the patch I found the stupid vet tech had poked a hole in the top corner of the sac with a staple! For all I know it leaked & my cat got an overdose. Also my cat had lung cancer, and the insert says not to use Fentanyl on anybody with lung disease. I wish it was possible to sue vets for malpractice!

[aKaMumbles]

@Midnightryder7 Please don't tell people to do this.

[mauriceh01]

wow that's some crazy shyt!