Mom Hopes Son's Overdose Spurs Prevention Efforts

As seen in Consultant Connection June / July 2012 Issue
ISMP NurseAdvise-ERR May 2012

A grieving mother recently contacted the Institute for Safe Medication Practices (ISMP) about the death of her 2-year-old son, Blake (see photo), from an accidental drug overdose. Her son was not ill, he was not taking any medicine, and he was not hospitalized. Instead, the tragic event began, of all places, at a longterm care facility.

Last November, the family was visiting the boy's great-grandmother at the long-term care facility. Two days after the visit, Blake was found unconscious and in respiratory arrest, and emergency medical personnel were unable to revive him. A medical examiner later found a small, white, 1 x 1.5 inch piece of what appeared to be tape in the boy's throat. Later, after a toxicology report indicated that a lethal dose of fentaNYL was in Blake's system, the "tape" was sent to a lab to be analyzed. The tape turned out to be a fentaNYL patch.

An investigation led to the long-term care facility where the boy had visited days earlier. Authorities found that medication patches were not being discarded properly. A used fentanyl patch was found on a bedside table. Authorities also found used medication patches in other resident's rooms on the fl oor, stuck to bed railings, and in other unsecured patient areas. Blake's mother also stated that patches had been discarded in the trash bin in the great-grandmother's room.

One theory is that Blake may have run over a used fentaNYL patch on the floor of his great-grandmother's room while playing with his toy truck. The patch probably stuck to the wheels of the toy. Later, he may have peeled off the patch and put it in his mouth. From there, the fentaNYL began absorbing into his body. The patch then became stuck in his throat. A used fentanyl patch can still contain a large amount of unabsorbed medication. So, both new and used patches can be dangerous to children (and pets).

This theory about the child's death is quite feasible given that there have been reports of other children who have been exposed to patches in a similar manner. In fact, we have received a number of reports over the years about children being accidentally exposed to used fentaNYL transdermal patches. A 4-year-old boy died after placing a fentaNYL patch on his body. His mother had been using these patches for pain from Crohn's disease. After she found her son dead, she also found a torn fentaNYL patch wrapper in an overturned bedroom trash can. Children have also been exposed to danger from medication patches that have fallen off a family member. In one case, the child sat on the fallen patch and it stuck to her upper thigh. Another child removed a patch while his grandmother was sleeping and applied it to himself. In these cases, the patches were noticed right away and the children were not injured.

In April 2012, the US Food and Drug Administration (FDA) alerted the public to this risk ( FDA reported that 26 children have been accidentally exposed to fentaNYL patches during the past 15 years. Ten children have died, and 12 were hospitalized. Sixteen cases involved children 2 years old or younger Blake's mother asked us to share information about how to properly use, store, and dispose of fentanyl patches, which can be found to the right. She also asked us to emphasize that parents need to be aware of possible hazards when they visit a healthcare facility with their child. She warns, "You can't count on people not making mistakes like dropping pills or forgetting them on a bed rail. Parents should keep a close eye on their kids when visiting someone where any medicine is used." Regulatory agencies should also require safe patch disposal in all healthcare facilities.

Follow these suggestions for safe medication patch use, storage, and disposal.
  • Keep track of patches on the body.While medication patches have adhesive backings, they do not always stay on the skin. Patients and their caregivers should be taught to regularly check to make sure the patch is still where it belongs, particularly soon after awakening, after a shower, and anytime clothes or bed sheets are changed. The healthcare professional or caregiver who applies the patch should document its placement and check its location during routine assessments. Always ensure it is removed before applying a new patch.
  • Dispose of patches safely. As a precaution, the FDA instructs patients to fold the adhesive side of a used fentaNYL patch together and fl ush it down the toilet. Only after a used fentaNYL patch has been disposed of properly should a new patch be placed on the patient. The used patch should never be placed temporarily on a bedside table or stuck to a bed rail while applying a new patch.
  • Keep out of reach. Patients who will be using medication patches at home should be educated to keep new patches far away from the reach or discovery of children, and to not let children see them apply patches or call them stickers, tattoos, or special Band-Aids. This could attract children and encourage them to mimic their actions.
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