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Beware of overdoses associated with skin patches

Patient Safety Monitor Alert, October 18, 2004

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Beware of overdose dangers associated with skin patches

Transdermal patch delivery systems are more vulnerable to errors when the frequency of application varies, since clinicians and patients may be unaware that a significant amount of medication remains in the patch long after the application period has expired, according to a summary of errors reported to Pennsylvania's Patient Safety Authority Reporting System (PA-PSRS), an independent state reporting system.

Errors associated with fentanyl (Duragesic) patches pose the greatest risk of harm. Fentanyl is considered a high-alert medication in PA-PSRS, which means that it has a greater risk of harming a patient when errors occur, according to a report in the PA-PSRS-produced newsletter Patient Safety Advisory (Vol. 1, No. 3).

Although Duragesic patches are supposed to be replaced every 72 hours, PA-PSRS has received several reports of clinicians discovering multiple fentanyl patches on patients. Upon examining one elderly female patient, for example, a clinician discovered two patches adhered to the patient's back. The patient supposed to receive Duragesic 75 mcg/hour, and the added dose affected her mental status. After the clinician removed the outdated patch, the patient's vital signs improved and her mental status returned to normal.

PA-PSRS outlines the following strategies to help reduce errors associated with transdermal patches:

1. Treat the removal of patches as if they are part of the medication order by listing details of the removal process on the medication administration record , including the exact time it was removed and where a new patch was applied

2. Include a prompt on intake and pre-op assessment forms that will remind clinicians to double-check whether the patient is already wearing a patch

3. Educate all practitioners regarding transdermal delivery of medications, including about the importance of checking for and removing outdated patches

-- wjohnson@hcpro.com

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