From the June 2008 issue

We’ve often stressed the importance of patient education when dispensing fentanyl transdermal system patches. Another tragic event in which a 6-year-old girl died and her foster mother is charged with criminal gross negligence in her accidental death reinforces this imperative. When the child complained of neck pain late one evening, her foster mother gave her an appropriate dose of ibuprofen but also placed a leftover fentanyl patch on the child’s neck to help treat the pain. The next day, the child was found unconscious in bed and was pronounced dead by the time she arrived in the emergency department. The child’s foster mother had been given a prescription for fentanyl patches several years earlier to treat chronic pain after an accident. The patch she placed on the child was leftover from that prescription. The criminal charges against the foster mother were based on the severity of the error, called “gross negligence” in legal terms. This tragedy may have been avoided had the foster mother received adequate education when the fentanyl patches were prescribed and dispensed.