A 15 month old child has died from accidental overdose with a fentanyl patch. Fentanyl is far more potent than heroin. The dose contained in a patch is known to be deadly to children. Unusually, compared to other dosage systems, patches remain pharmacologically active after use. They can fall off, transfer to others, or be picked up out of a bin. The FDA reported on 32 cases, mostly in children under 2, with 12 deaths.
The MHRA warned of these risks in 2008, and in 2014. After this death, the MHRA stated they will continue to monitor the situation, and it is reported that the coroner will be asking for a further “national warning to alert healthcare professionals about the risks associated with the patches.”
Drug safety risk communication is complex.
Patients don’t always read patient information leaflets.
Prescribers don’t read Summary of Product Characteristics.
Regulator safety messages don’t get attention.
Professionals’ communications are cursed by knowledge.
Tobacco health warnings are not hidden in information leaflets. They are not provided to suppliers.
They are on the product, graphic, and they are [PDF]:
- in English
- fully visible
- irremovably printed
- printed on the pack
- surrounded by a black border
They are high impact. Perhaps this is an approach we can learn from?
“Shoes” from David Maxwell.