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What’s New in the Patient Safety World

June 2021

ISMP on Patch-Related Issues

Transdermal medication patches are an effective way to administer certain medications under appropriate circumstances. But there are also dangers associated with their use. We’ve noted that discarded patches may still contain active drug and children and pets may be exposed to them. We’ve also noted how a second patch may be applied to a patient’s skin, not recognizing the presence of another patch, resulting in an overdose for the patient. And we’ve also noted that patches containing metal or ferromagnetic components may overheat during MRI scanning, resulting in burns. Most of our columns have dealt with opioid patches, particularly Fentanyl, but problems may occur with virtually any transdermal patch.

ISMP (Institute for Safe Medication Practices) recently reported on more than 50 reports associated with 12 different transdermal medication patches submitted to the ISMP MERP within the past 4 years (ISMP 2021). Patches most frequently involved in reported errors included fentaNYL (n = 16), cloNIDine (n = 10), scopolamine (n = 7), and estradiol (n = 6). ISMP categorized the problems in the following areas:

• Errors in the Frequency of Patch Application or Removal
• Lack of Awareness of Patches on the Patient’s Skin
• Dose Confusion Due to Labeling
• Inappropriate Patch Prescribing
• Wrong Dose Dispensing Errors
• Patch Cover Applied without the Medication Patch
• Wrong Patch Prescribed Due to Similar Ingredients
• Miscellaneous Errors

ISMP reiterated the problem of failing to identify patches on the patient’s skin, not removing an old patch when applying a new patch, and/or finding multiple patches on patients that had been left on longer than prescribed. Hospital admission may be a time of vulnerability to the first failure, since a patch applied prior to admission might be easily overlooked. Failure to recognize prior patches or presence of multiple patches on the skin of some patients may be more likely with those patches that are clear or beige.

Inappropriate patch prescribing applied most often to fentaNYL patches. Our multiple columns on long-acting opioids have stressed that these are intended for opioid-tolerant patients and should not be prescribed for acute pain or in opioid-naïve patients.

We encourage you to read ISMP’s full article. It provides examples in each of the above categories and provides very important recommendations for all patches and for specific patch types.

Our prior articles pertaining to long-acting and/or extended release preparations of opioids:

• April 2010 “RCA: Epidural Solution Infused Intravenously”
• July 13, 2010 “Postoperative Opioid-Induced Respiratory 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”
• September 2013 “ISMP Outreach on Fentanyl Patch Safety”
• October 2013 “Opioid Safety Actions and Resources”
• February 24, 2015 “More Risks with Long-Acting Opioids”
• February 2017 “FDA Approves Even More Long-Acting Opioids”
• February 12, 2019 “2 ER Drug Studies: Reassurances and Reservations”
• February 2020 “The FDA and Long-Acting Opioids”
• August 2020 “Fentanyl Patches in the Crosshairs Again”

Our prior columns on iatrogenic burns:

• March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
• June 1, 2010 “Iatrogenic Burns”
• October 5, 2010 “More Iatrogenic Burns”
• December 23, 2014 “Iatrogenic Burns in the News Again”
• March 2015 “Another Source of Iatrogenic Burns”
• September 5, 2017 “Another Iatrogenic Burn”
• June 5, 2018 “Pennsylvania Patient Safety Authority on Iatrogenic Burns”
• July 28, 2020 “Electrosurgical Safety”
• January 2021 “New MRI Risk: Face Masks”

References:

ISMP (Institute for Safe Medication Practices). Analysis of Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety Challenges. ISMP Medication Safety Alert! Acute Care Edition 2021; 26(5): March 11, 2021

https://www.ismp.org/resources/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-challenges

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