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ALERT: Transdermal patches

15 Nov 2021

Purpose: To highlight the risks associated with the use of transdermal patches (both from the medicine and the delivery system).

Transdermal patch alert updated (September 2019)

A recent case highlights the importance of the correct placement of transdermal patches in patients with cognitive impairment.

In this case a patient with cognitive impairment was admitted to hospital and prescribed their usual fentanyl patch. The patient’s old patch was removed and a new patch applied. The new patch was applied to the patient’s upper arm, however the patient removed the patch and put it in their mouth. The patient was found with reduced consciousness and myoclonic seizure-like movements.

For cognitively-impaired patients, it is recommended that any patch is applied to the upper back/scapula area where the patient cannot reach or remove it.

The Commission’s transdermal patches alert has been updated to reflect this recommendation. The list of transdermal patches available in New Zealand has also been updated (September 2019).

Please review your individual practice, your organisation’s guidelines for transdermal patches and patient information leaflets to ensure they include guidance on the placement of transdermal patches in cognitively-impaired patients.