Error Alert
Institute for Safe Medication Practices
A recent cluster of error reports associated with transdermal medication patches submitted to the Institute for Safe Medication Practices National Medication Errors Reporting Program (ISMP MERP) led us to look back a few years at all transdermal patch error reports submitted to the ISMP MERP.
A transdermal patch is a medicated adhesive patch placed on intact skin to provide regular, controlled release of medication doses into the bloodstream.
Transdermal patches are used to deliver a wide variety of pharmaceuticals, including medications used for smoking cessation, hormone replacement therapy, hormonal contraception, hypertension, angina, pain, depression, and Alzheimer’s disease.
In our analysis, errors in the frequency of patch application or removal were more frequently reported than other types of errors.
A number of these frequency errors involved estradiol patches. Depending on the brand or formulation, estradiol patches are applied either twice a week (i.e., ALORA by Allergan, DOTTI by Amneal Pharmaceuticals LLC; LYLLANA by Amneal Pharmaceuticals LLC; MINIVELLE by Noven Pharmaceuticals; Vivelle-DOT by Novartis; generics) or once a week (Climara by Bayer, MENOSTAR by Bayer, generics).
In two of the cases, a weekly estradiol patch was prescribed, but a twice- weekly formulation was dispensed with directions to apply one patch weekly.
In another case, a prescriber ordered a twice-weekly estradiol patch, but the pharmacy dispensed a weekly patch with directions to apply the patch twice weekly.
Some dispensing errors continued for several refills. In some cases, the manufacturers’ outer cartons did not clearly specify if the patch was to be applied weekly or twice-weekly.
We also received reports of dispensing fentanyl patches with the wrong directions for application, sometimes due to a transcription error in the pharmacy. Another error in this category involved misinterpretation of a consultant’s note to “Increase Clonidine patch to TTS-2 to mitigate ketamine side effects and help with opioid withdrawal symptoms.” The physician interpreted the “TTS-2” to mean Tuesday, Thursday, and Saturday, and did not know that “TTS-2” was the nomenclature used for the 0.2 mg/24-hour CATAPRES-TTS-2 (transdermal therapeutic system) brand of clonidine patches, which should only be applied weekly.
To help prevent the wrong frequency errors described above, consider the following recommendations.
All patches
- Collect medication history from each patient. Use scripted questions or prompts to help identify all medications and substances that may not be readily identified by patients. Specifically question patients regarding the use of any type of patch.
- Within electronic prescribing systems, create medication patch order sentences that include the appropriate application frequency.
- Consider allowing the entry of only the appropriate application frequencies. For example, only allow entry of the frequency of fentanyl patch application every 72 hours or every 48 hours, not every 24 hours.
- Place prompts on long-term care medication administration records to document the location of all medication patches applied and link all entries for medication patches to an order for removal at the appropriate interval.
- Provide verbal and written education to patients and caregivers on the use of patches (e.g., when to remove and replace the patch), including how to establish a system (e.g., calendar or alarm reminders) for the appropriate cadence of patch application and removal. Discuss any related safety concerns and error potential. Always verify the patient’s understanding of the information. (For an ISMP fentanyl patch consumer leaflet, visit: www.ismp.org/sites/default/files/attachments/2018-11/fentanyl1-13.pdf.)
Specific patches
- Estradiol: Include brand names when prescribing estradiol patches since they have different application frequencies. If it is unclear which product is to be dispensed, the pharmacist should verify the prescription with the prescriber.
- Opioid: Default prescribing systems to the lowest initial starting dose and frequency.