She kept the remaining ones: A fatal fentanyl patch drug error

After an accident several years ago, a woman got a prescription for fentanyl patches to treat her chronic pain. She didn't use all the patches, and kept the remaining ones.

Years later, her six-year-old daughter complained of neck pain late one evening. The foster mother gave her an appropriate dose of ibuprofen, and placed one of the left-over fentanyl patches on her neck to treat the pain. The next day, the girl was found unconscious in bed, and was pronounced dead by the time she arrived in the hospital’s Emergency Room.

Mike Cohen's advice to parents: Discard unused prescription medication after you're done with it. Ask your pharmacist about the safe use of fentanyl patches. Don't share fentanyl patches with anyone else.

Read another Fentanyl story.

Thanks to Michael Cohen for the source story in his ISMP Medication Error Report Analysis, published in Volume 43, Number 9 of Hospital Pharmacy.