A Tragic Overdose Due to a Fentanyl Patch Dosage Error

A woman has suffered a severe overdose after being dispensed six times the prescribed dose of a fentanyl patch by her pharmacy. The incident has raised serious concerns about medication safety and the potential for human error in pharmaceutical services. The Pharmacy Council has launched an investigation into the matter, while the involved pharmacy has described the mistake as a result of 'human error.'

The Incident

The woman, who has chosen to remain anonymous, visited her pharmacy on 24 July to collect a prescription for Fentanyl Sandoz. She was informed that the product was unavailable at the time. Two days later, on 26 July, she returned to the pharmacy and was given fentanyl patches that released 75 micrograms per hour, totaling 1.8 milligrams per day. This was significantly higher than the prescribed dose of 12 micrograms per hour and 0.3 milligrams per day.

The woman applied the first patch around 8pm. Within two hours, she began experiencing severe nausea. By 1am, she was violently vomiting and unable to move. Fearing the severity of her condition, she eventually removed the patch and contacted the pharmacy the following day. The pharmacy expressed concern over the incident and offered compensation for the time she had to take off work.

Pharmacy Response and Ongoing Investigations

The pharmacy owner confirmed that the matter is currently under investigation by the Pharmacy Council and has declined to comment further on the incident. A spokesperson for the Pharmacy Council stated that an inquiry is underway to determine the full extent of the error and its implications.

Authorities have also stepped in, with the Ministry of Health and Health New Zealand reviewing the situation. MedSafe, New Zealand's medicines regulatory authority, has visited the pharmacy to assess its safety and ensure that it can continue to operate without posing a risk to the public.

Broader Concerns in the Healthcare System

This incident is not an isolated case. It follows the tragic death of a two-month-old baby, Bellamere Arwyn Duncan, who was administered more than 13 times the prescribed dose of phosphate by a pharmacy. This event has prompted a joint review by the Ministry of Health and Health New Zealand, highlighting the need for systemic improvements in medication management and error prevention.

Such errors raise critical questions about the training and oversight of pharmacy staff, as well as the protocols in place to prevent dispensing mistakes. While the pharmacy described the error as a result of 'human error,' it is essential that the healthcare system learns from such incidents to prevent future tragedies.

As the investigations continue, it is crucial that all stakeholders—pharmacies, healthcare professionals, and regulatory bodies—work together to ensure that patients receive the correct medications and dosages, and that such errors are minimized in the future.