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Prescription of an excessive dose of fentanyl patch (14HDC01100)
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General practitioner ~ Controlled medication ~ Pain
management ~ Information ~ Rights 4(1), 4(2), 6(1)(b),
A woman had a spinal fusion and decompressive surgery. Four days
later the woman was discharged from hospital with a hospital
discharge form that outlined she had been taking a 12.5mcg fentanyl
patch every 72 hours for pain control. The woman was given one
12.5mcg fentanyl patch and told to visit a general practitioner
(GP) should she require more.
Following the woman's surgery she recovered at her partner's
house in another region. Seven days after the surgery the woman
visited a medical centre as a casual patient. The woman was seen by
a GP for approximately 10 minutes, during which the woman showed
the GP the hospital discharge form. At the appointment, the woman
complained of pain and an inability to sleep. The GP prescribed her
two boxes of five patches of 100mcg fentanyl. The GP did not advise
her of possible fentanyl side effects. The GP did not document, or
save, the record of the appointment with the woman.
The woman filled the prescription at a pharmacy. The pharmacist
dispensing the medication dispensed only one box of five patches,
and advised the woman to return if she required the second box.
After the prescription was filled, the woman went to her
partner's house and, being in pain, put on a 100mcg fentanyl patch.
That evening, at approximately 1am, the woman was taken to the
emergency department (ED) because she was dizzy, nauseous and had
vomited. In the ED, the woman's dose of fentanyl patch was
decreased to 25mcg.
It was held that, by prescribing an excessive dose of fentanyl
to the woman, the GP breached Right 4(1). For failing to warn of
the side effects of the medication that the woman was being
prescribed, the GP breached Right 6(1)(b) and Right 7(1). By having
no clinical record of his appointment with woman, the GP breached
The medical centre was not directly or vicariously liable for Dr
B's breaches of the Code.