Advicor

TRANSDERMAL MEDICATION

A 63-year-old obese woman went to the ED with uncontrolled pain due to multiple chronic conditions. When asked about her medications, she listed all her oral medications but didn't mention that she was wearing a transdermal patch containing the opioid fentanyl (75 meg/hour). She was admitted to a medical unit with orders for application of a fentanyl patch (50 meg/hour) every 72 hours and I.V. morphine for breakthrough pain. The patch was applied that evening.

The next day, the patient was found unresponsive. She was intubated and given a dose of the opioid antagonist naloxone, but her response was marginal. She was transferred to the ICU, where a nurse thoroughly examined her and found both fentanyl patches applied to her skin; the one she'd been wearing at admission was buried deep in a skin fold. The nurse removed both patches and the woman eventually recovered.

This patient hadn't been asked if she was currently wearing a medication patch nor had she been sufficiently educated to question why a second fentanyl patch was being applied. Before you apply a transdermal patch, ask the patient whether she's wearing one. You might also perform a complete skin assessment before applying any transdermal opioid patch to check for patches the patient may have forgotten.

Name change

Andrx Corp. has changed the name of its cholesterol-reducing lovastatin from Altocor to Altoprev because the former name posed a risk of confusion with Advicor (sustained-release niacin and lovastatin), which is also prescribed to lower cholesterol.

The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at http://www.ismp.org or the United States Pharmacopeia (USP) at http://www.usp.org. You can also call ISMP at 1-800FAIL SAFE or send an e-mail message to ismpinfo@ismp.org.

Copyright Springhouse Corporation Sep 2004
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