A serious threat to patient safety: the unintended misuse of FentaNYL patches.

entaNYL transdermal patches (Duragesic and other generic brands) are a mainstay in the treatment of Fchronic pain, yet the US health care community and patients alike continue to face challenges regarding the safe use of this product. Despite numerous warnings from drug manufacturers, patient safety groups, and even the Food and Drug Administration (FDA), the Institute for Safe Medication Practices (ISMP) continues to receive serious event reports about FentaNYL patches to its national medication error reporting program. Unfortunately, a significant number of reports of FentaNYL patch misuse have resulted in patient harm and even death. Tragically, on further investigation, most of these events were found to be preventable. Such events are described herein.