MEDICATION ERRORS: Assembling a patchwork quilt
MICHAEL R. COHEN RPH, MS, ScD, President of the Institute for

$3.95 		Nursing2013
September 2004 
Volume 34  Number 9
Pages 14 - 14
 
  PDF Version Available!

ABSTRACT
Outline

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    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 mcg/hour). She was admitted to a medical unit with orders for application of a fentanyl patch (50 mcg/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 ...

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