In the first case, the person reporting the event described a post-operative patient with a morphine infusion running immediately after surgery, who was discharged the next day. In the past few weeks, we received two more reports of prescribing errors-one of which was fatal. In our newsletter, we reported that an elderly patient had several fentanyl patches totaling 125 mcg/hour applied to her skin, which caused delirium and led to her transfer to a critical care step-down unit for close observation. Despite these warnings, label changes, and publication of prescribing problems in ISMP newsletters and elsewhere, some practitioners still seem unaware of the dangers with this potent narcotic and the proper prescribing guidelines (see Table 1). Likewise, FDA issued a Public Health Advisory to alert healthcare providers that deaths and overdoses had occurred in patients using both the brand name product Duragesic and the generic product. The databases to which ISMP has access bear proof of this ongoing safety issue, and numerous case reports have already appeared in previous editions of ISMP newsletters (JAugSeptember 19, 2001).Īs noted two years ago in our Augnewsletter ( New fentanyl warnings: more needed to protect patients), Ortho-McNeil (Janssen), maker of DURAGESIC (fentanyl transdermal), issued a “Dear Health Professional” letter to bring attention to new boxed warnings in the product label related to improper prescribing. ISMP is deeply troubled by these practices and alarmed by what appears to be a steady stream of reports of adverse events with fentanyl patches-including fatalities-caused by inappropriate prescribing, dispensing, and administration of the drug. Unfortunately, pharmacists have often filled these prescriptions without question, and nurses caring for patients have applied the patches without recognizing the prescribing error. Some of these prescribing errors have occurred in hospitals others have originated in physician offices or ambulatory surgery centers, where well-meaning but misinformed primary care physicians or surgeons have prescribed the drug for opiate-naïve patients under contraindicated circumstances such as acute post-operative pain. Problem: Despite warnings from the FDA, manufacturers, and various patient safety agencies, fentanyl transdermal patches continue to be prescribed inappropriately to treat acute pain in opiate-naïve patients, sometimes in large doses or in combination with oral or intravenous opiates.
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