Fentanyl Med Error?

Nurses Nurse Beth


Specializes in Tele, ICU, Staff Development.

Dear Nurse Beth,

I have a resident who has a fentanyl patch. When I read the paper MAR where the day was blocked off it looked as though it was due yesterday so I cut the patch opened and then double checked the date after I read the date on the old patch which was still applied to the resident.

I realized that it was due until today so I did not apply or take the old one off. I told my supervisor and everything was still intact except the foil package had been cut. patch still in between the plastic. They are now calling it a med error. I don't understand how it is a med error I did not apply a new one or remove the old one. Please enlighten me.

Dear Enlighten Me,

Is their concern a medication error or is their concern possible drug diversion?

I cannot see where this is a med error. It's more of a near miss or good save, but not an error.

How was the foil opened patch disposed of? If the patch was wasted and witnessed according to policy, then you did the right thing.

Best wishes,

Nurse Beth


Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

Dear Fentanyl Patch Medication error.

You could have just wasted the Fentanyl Patch with another RN, therefore, your superiors could not fault you for anything.

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