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.

He was found dead at his computer: A Fentanyl overdose

Adam Hendelson had been in a car accident as a teenager. For years, on his right arm he had worn a Duragesic patch, containing Fentanyl gel, to manage his chronic hip pain. In December 2003, at age 28, he was found dead at his computer. The cause was traced to a leak in the patch that had given him a fatal overdose. In June 2007, a Florida jury awarded his family $5.5 million.

Last week, noticing that hundreds of people had died from similar accidents, the Food and Drug Administration issued a warning about the use of Fentanyl. The FDA warned doctors against prescribing Fentanyl patches to anyone new to opioids, the family of painkillers that includes morphine. The drug is only to be used for chronic pain in people who are used to using narcotics, such as cancer patients. Fentanyl can cause other people to have trouble breathing.

Advice to those with family members using Fentanyl patches: Read the FDA warning.

Browse for related stories in the index at the very bottom of this page, or read a less harmful story about conscious sedation.

Thanks to Lauran Neergaard of the Associated Press and Kenneth Reid for the source stories in the Dec. 22 issue of the Boston Globe and the June 18 issue of Adverse Event Reporting News, respectively.