Abstract
ObjectiveA few cases of adverse reactions linked to erroneous use of transdermal opioid patches have been reported in the literature. The aim of this study was to describe and characterize medication errors (MEs) associated with use of transdermal fentanyl and buprenorphine.MethodsAll events concerning transdermal opioid patches reported between 2004 and 2011 to a regional incident reporting system and assessed as MEs were scrutinized and characterized. MEs were defined as “a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient”.ResultsIn the study 151 MEs were identified. The three most common error types were wrong administration time 67 (44%), wrong dose 34 (23%), and omission of dose 20 (13%). Of all MEs, 118 (78%) occurred in the administration stage of the medication process. Harm was reported in 26 (17%) of the included cases, of which 2 (1%) were regarded as serious harm (nausea/vomiting and respiratory depression). Pain was the most common adverse reaction reported.ConclusionsOf the reported MEs related to transdermal fentanyl and buprenorphine, most occurred during administration. Improved routines to ascertain correct and timely administration and educational interventions to reduce MEs for these drugs are warranted.
Highlights
The usage of transdermal patches which allows continuous and prolonged delivery of medications is increasing
Lower peak plasma drug concentration compared with other types of administration forms and avoidance of first-passage metabolism are some reported benefits suggesting that this administration form may have increased compliance, effectiveness and safety compared to oral administration [1,2]
Since potent drugs linked to serious adverse reactions are administered through transdermal patches, medication errors may lead to serious adverse health consequences
Summary
The usage of transdermal patches which allows continuous and prolonged delivery of medications is increasing. Sporadic case reports indicate specific problems related with this drug form, such as incorrect use of multiple patches [3,4], ingestion of used or unused patches [5] and skin reaction [6]. Since potent drugs linked to serious adverse reactions are administered through transdermal patches, medication errors may lead to serious adverse health consequences. There are previous reports of serious and fatal cases due to erroneous administration of multiple patches of rivastigmine, an anticholinergic drug used to treat dementia [4,10]. Prevalence and characteristics of medications errors related to transdermal opioid patches has not been systematically compiled and presented in the scientific literature and such information is needed to develop effective preventive measures. This study was undertaken to describe and characterize medication errors regarding transdermal opioid patches, containing fentanyl and buprenorphine, submitted to a regional incident reporting system
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