Safety Issues with Fentanyl Patches Require Pharmaceutical Care

摘要

Contributions to this column are prepared by the Institute for Safe Medication Practices Canada (ISMP Canada), a key partner in the Canadian Medication Incident and Prevention System, and include, with permission, material from the ISMP Canada Safety Bulletin. From time to time, ISMP Canada invites others to share learning based on local initiatives.In September 2007, the media reported that the chief coroner for Ontario had launched an investigation into 3 patient deaths that appeared to be associated with the use of fentanyl patches.1 The same report noted that "at least 3 more deaths in British Columbia have been linked to the same drug". A search (on November 26, 2007) of the medication incident database maintained by the Institute for Safe Medication Practices Canada (ISMP Canada) identified 163 reports of incidents involving fentanyl patches, 14 of which had resulted in patient harm, including 1 death.