September 2013
ISMP Outreach on Fentanyl Patch Safety
ISMP has just
identified another tragedy related to fentanyl patches and has issued an appeal
for all providers to take action to prevent similar incidents (ISMP
2013). We’ve written frequently about the dangers of fentanyl, especially
fentanyl patches (see the list at the end of today’s column).
The new case
identified by ISMP involved a 15-month old baby who was cuddling with his
mother while both napped. The mother was wearing a fentanyl patch on her chest
at the time. When she awakened the baby was unresponsive and the patch missing.
The child was taken to a hospital but could not be resuscitated and died. The
presumption was that the baby had ingested the patch.
This is but one in a
tragic series of similar events regarding accidental deaths due to contact with
or ingestion of fentanyl patches. ISMP notes we are all guilty of “bystander
apathy” when we see such cases and assume that someone else will fix the
problem. They call for increased efforts on the parts of physicians, nurses,
pharmacists, hospitals, professional organizations, safety organizations,
pharmaceutical companies, the FDA, and licensing and accrediting organizations
to raise awareness of this serious issue.
The ISMP article
above has links to their free patient education checklist and consumer
leaflet plus links to several FDA resources to help with education around
safety of fentanyl patches. ISMP stresses that no patient should ever be
allowed to walk out of a doctor’s office, hospital, clinic or pharmacy without
face-to-face instructions on the use and safety issues surrounding fentanyl
patches.
The recent ISMP
article reiterates many of the previous cases and has an excellent discussion
on pharmacodynamics of the fentanyl patches based upon the mode of exposure.
They note that the patches are designed for slow absorption through the skin
over 72 hours but that ingestion of patches leads to much more rapid absorption
via the buccal route, resulting in very high blood and
tissue fentanyl levels. Chewing the patch leads to even higher levels. And they
note that even used patches (i.e. those already worn for 72 hours) may
still contain very significant amounts of drug.
Children,
particularly those under the age of 2, have been especially prone to
accidentally ingest or otherwise absorb fentanyl from such patches. Note also
that pets are vulnerable. So the educational piece must involve information not
only about use of fentanyl patches but also about safe storage and disposal.
Our September 13,
2011 Patient Safety Tip of the Week “Do
You Use Fentanyl Transdermal Patches Safely?” and our May 2012 What’s New
in the Patient Safety World column “Another
Fentanyl Patch Warning from FDA” had numerous recommendations regarding
what you should be doing to improve safety of fentanyl patches.
We strongly
encourage you to make all in your organization aware of the issue and the
availability of these educational resources for your staffs and patients and
families. ISMP has always taken the lead on this issue but we can no longer let
them carry the ball themselves. It’s all or our responsibilities to prevent
another tragedy from occurring.
Fentanyl patches
should be one of your high alert medications. If you are looking for a topic
around which to conduct a FMEA (failure mode and effects analysis) you can’t
beat this one for identifying multiple areas of potential vulnerability.
Some of our other Patient Safety Tips of the Week
regarding fentanyl and fentanyl patches:
- April 2010 “RCA: Epidural Solution Infused Intravenously”
- July 13, 2010 “Postoperative Opioid-Induced Respiraatory Depression”
- January 18, 2011 “More on Medication Errors in Long Term Care”
- April 12, 2011 “Medication Issues in the Ambulatory Setting”
- June 28, 2011 “Long-Acting
and Extended-Release Opioid Dangers”
- September 13, 2011 “Do
You Use Fentanyl Transdermal Patches Safely?”
- November 8, 2011 “WHO’s Multi-Professional Patient Safety Curriculum Guide”
- May 2012 “Another
Fentanyl Patch Warning from FDA”
- July 24, 2012 “FDA
and Extended-Release/Long-Acting Opioids”
- September 2012 “Joint Commission Sentinel Event Alert on Opioids”
- March 2013 “Try
Googling Fentanyl Accidents”
References:
ISMP (Institute for Safe Medication Practices). FentaNYL patch fatalities linked to “bystander apathy”. We ALL have a role in prevention! ISMP Medication Safety Alert! Acute Care Edition 2013. August 8, 2013
http://www.ismp.org/Newsletters/acutecare/showarticle.asp?id=55
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