SAFETY MEMO 17
To:
Directors of Pharmacy/Heads of Pharmacy and Medicines Management, HSC
Trusts and Mr J Brogan, Assistant Director Commissioning - Pharmacy and Medicines
Management, HSC Board
Dr N Morrow, Chief Pharmaceutical Officer, DHSSPS
Cc:
From: Daryl Connolly, on behalf of the Medicines Governance Team
Date: 13th September 2012
The safe use of opioid transdermal patches
Opioid medicines are designated as ‘high alert medications.’ Opioid patches are often reported
as causing patient harm and in recent years the MHRA, NPSA, ISMP and FDA have issued
safety warnings on the safe use of opioids following reports of serious adverse events and
death related to overdoses 1,2,3,4. The Medicines Healthcare Products Regulatory Agency
reported that accidental overdoses are commonly related to:



Dosing errors (by healthcare professionals, patients or caregivers)
Accidental exposure (particularly in children)
Exposure of the patch to a heat source, resulting in increased absorption
A recent document from the Department of Health, Social Services and Public Safety
(DHSSPS) – Supporting Safer Services5 specifically alerted staff to potential problems that
may arise with opioid patches.
In response to this document the Medicines Governance Team have developed a poster to
reinforce the key safety factors associated with opioid patches, these include:





Prescribing
Storage and disposal
Safe use
Heat
Signs of overdose
Please distribute this poster within your Trust.
If you have any further questions, pleased do not hesitate to contact your Medicines
Governance Pharmacist.
References
1. Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update. Fentanyl Patches: serious and fatal overdose from dosing
errors, accidental exposure and inappropriate use. Volume 2, Issue 2 September 2008.
2. National Patient Safety Agency (NPSA), Rapid Response Report. Reducing dosing errors with opioid medicines. 4th July 2008.
3. Institute for Safe medication Practices (ISMP), Medication Error Report Analysis. On-going incidents involving Fentanyl Patches are alarming.
Hospital Pharmacy, Volume 42, Number 10 pages 884 – 888.
4. US Food and Drugs Agency (FDA), reminds the public about the potential for life threatening harm from Accidental Exposure to Fentanyl
Transdermal Patches. 18th April 2012.
5. Department of Health, Social Services and Public Safety (DHSSPS) – Supporting Safer Services. A summary of key themes and learning arising
from serious adverse incidents reported to the DHSSPS between 1st April 2007 and 30th April 2010.