Mitigating risk

Using transdermal patches in a health or social care setting includes several steps, each associated with a risk of error. We provide practical advice at the key stages in the application  and removal process of transdermal patches. This advice does not replace manufacturers’ instructions which should always be read for patch specific advice.

Application and removal

Before application

Staff should make the following checks:

1. RIGHT person
2. RIGHT medicine
3. RIGHT route
4. RIGHT dose
5. RIGHT time
6. RIGHT documentation
7. RIGHT to decline

Check the pharmacy label carefully

Confirm the correct frequency or interval on the pharmacy label on the product packaging, as this can vary from days to weeks.

Choose and prepare the application site

• Rotate the site of application each time a patch is applied. Refer to administration records to check the previous application site. Using the same site every time can cause skin irritation.
• Some patches can cause a thinning of the skin. If routinely applied to the same area, the rate of absorption into the bloodstream can be higher. This could lead to an overdose of the medication.
• Ensure the skin is dry, intact and not irritated.
• A flat area of hairless skin is a suitable application site. The person’s hair may need need to be clipped to give better adhesion.
• The upper back may be preferable in a confused person, to reduce the risk of unintended patch removal. First refer to local procedures on capacity and consent.

Staff should not:

• Expose the application site to oils, creamy soaps or moisturisers. This may cause irritation or cause allergic reactions when the patch is applied. It may also prevent the patch from sticking to the skin.
• Shave the hair as this may irritate the skin.
• Take the patch out of the wrapper until they are ready to apply it to the skin site.

During application

Staff should:

• Wash hands before and after application.
• Always ensure old patches are removed before applying a new one.
• Follow manufacturers’ product literature carefully for step-by-step instructions on the correct application technique.
• Instructions can be found on the product packaging or in the accompanying Patient Information Leaflet, or electronically via the  Electronic Medicines Compendium (eMC).
• Once applied, check the patch has adhered onto the skin properly, especially on the edges.
• Record the administration using their local documentation, including the date and time.
• If needed, write the date and time of application on the edge of the patch itself using a soft-tip permanent marker pen, taking care not to damage or tear the backing liner.

Avoid during application

Staff should not:

• Apply a patch immediately after a person has had a bath or shower as heat can increase the absorption of medicines in the patch. This could lead to an inadvertent overdose of medication.
• Touch the adhesive side of patches as inadvertent exposure to the medicine is possible.

Multiple patches

• Always consider the range of strengths available and if it is possible to use a higher strength rather than multiple patches.
• When more than one patch containing the same medication is needed, apply to the same area of the body but do not overlap the patches.

At removal

Staff should:

• Locate the patch (or patches) and check when it should be removed: ask the person to show them the location and check the electronic or written records.
• Check that there is no indication that the patch has been tampered with since application.
• Ensure that they are removing the correct patch, as people may be using more than one type of patch.
• Carefully remove the patch to minimise skin reactions.
• Clean the application site with water to remove leftover adhesive.
• Record  that the patch has been removed, including the date and time.

Avoid at removal

Staff should not:

• Apply another patch until the previous patch or patches have been located and removed or loss of patch confirmed.
• Touch the adhesive side of patches as inadvertent exposure to the medicine is possible.

Disposal after use

Staff should:

• Fold the used patch so that the adhesive side of the patch sticks firmly to itself.
• Remember used patches can contain residual medicine which can be fatal.
• Follow local disposal regulation to dispose of used patches e.g. CD waste disposal bin or sharps container.
• Wash hands thoroughly after handling the patches.

Cutting patches

Avoid cutting patches if possible:

• Cutting a patch will make the use ‘off-licence’.
• The release mechanism of the medicine could be adversely affected and release more medicine than intended.
• The resulting sharp edges could impair adhesion to the skin.

Before cutting a patch

Before cutting a patch, staff should:

• Consider the range of strengths available and if it is possible to use a lower strength rather than cutting patches.
• Consider if it is more appropriate to cover a portion of the patch to prevent contact with skin, in preference to cutting. Surgical adhesive tape (e.g. Micropore ^®) can be used on edges to aid adherence. Discuss this with the prescriber or pharmacist.
• Refer to the manufacturer’s literature for details on the type of patch.
• Make a decision to cut a patch on a case by case basis and not as routine practice.
• Discuss and obtain authorisation from  the prescriber if a patch is intended to be cut.

Types of patches

Patches contain either a ‘reservoir’ or ‘matrix’ of medicine that passes through the skin into the bloodstream. Refer to the manufacturer’s literature for details on the type of patch.

Reservoir patches

• The medicine is held in a reservoir with a rate-limiting membrane to control release of the medicine.
• Cutting these patches can cause the medicine to leak from the patch and is therefore not recommended.
• The exception is Scopoderm (hyoscine hydrobromide) 1.5mg patches, according to the BNF for Children. These can be cut with scissors along full thickness ensuring that the membrane is not peeled away.

Matrix patches

• The medicine is embedded in an adhesive matrix with the release rate determined by the physical properties of the matrix.
• The Matrix type patches can be sometimes cut.
• Seek advice from the pharmacist or the Medicines Information service that it is safe to cut the patch.
• Surgical adhesive tape (e.g. Micropore) can be applied to the edges to aid adherence.
• Dispose of the remaining part of the cut patch according to local policy. Only store the remaining part of the patch if stability information is available confirming that it is safe for further use.

Do not cut these patches

Some patches must not be cut:

• Reservoir style patches: Cutting these will cause the medicine to leak from the patch. (The exception is Scopoderm (hyoscine hydrobromide) 1.5mg patches, according to the BNF for Children )
• Any type of fentanyl patch (an opioid painkiller). The MHRA specifically advise not to cut fentanyl patches due to the risk of life threatening and fatal opioid toxicity.

Patch has fallen off

If a patch has fallen off, staff should:

Look carefully

Check the patch has fallen off completely. Check the patch records and ensure the patch is not stuck to another part of the body. Patches can fall off during showering or in bedding:

• If a patch has inadvertently transferred to another person, it should be removed immediately and medical help should be sought urgently.
• Consider whether the loss of a patch appears suspicious. Extra vigilance is necessary for patches containing controlled drugs, in secure environments (e.g. prisons, secure hospitals) and in some patient groups.

Record the incident

Document that the patch has fallen off using the locally agreed method for documentation:

• Seek advice from the prescriber if there is concern that treatment has been interrupted or a new prescription is necessary.
• Significant blood concentrations may exist for up to 24 hours because of the reservoir of medicine within the skin , but in some cases, dose re-titration may be recommended. Refer to the manufacturer’s literature.
• Be aware there is a risk of misappropriation with patches containing controlled drugs.

Apply a new patch

Apply a new patch to a different part of the body, once it has been confirmed that the patch has fallen off:

• Continue to change the patch on the usual day and time. e.g. if the patch is normally changed on a Monday and it falls off on Wednesday, replace it on Wednesday and change it as usual on Monday.
• Follow our advice on before application and during application.
• Consider using surgical adhesive tape (e.g. Micropore ^® ) to the edges to help with patch adherence.

Monitor for adverse effects

Monitor for increased adverse effects (due to potential increased serum concentrations) or loss of efficacy:

• Report any cases of accidental exposure where harm has occurred via the local incident reporting system or suspected side effects via the Yellow Card Scheme (www.mhra.gov.uk/yellowcard).
• In all cases, when unsure or concerned, seek advice from the prescriber or pharmacist.

Omitted or delayed patch application

Document that the patch has been omitted or delayed using the locally agreed method for documentation.

• Seek advice from the prescriber if there is concern that treatment has been interrupted or a new prescription is necessary.
• Significant blood concentrations may exist for up to 24 hours because of the reservoir of medicine within the skin but in some cases dose re-titration may be recommended. Refer to the manufacturer’s literature.
• Apply a new patch to a different part of the body
• Continue to change the patch on the usual day and time e.g. if the patch is normally changed on a Monday but you have now been applied it on Wednesday, change it as usual on the next Monday.
• Follow our advice on before application and during application.
• Monitor for loss of efficacy.

Switching to and from patches

Always seek advice from the  prescriber, pharmacist or the Medicines Information service if  are unsure on the appropriate gap to leave when switching to and from patches. This is important because:

• Blood concentrations of the medicine increase gradually after patch application and decrease gradually when removed.
• The time taken can vary considerably depending on the design of the patch and the active ingredient.
• Leaving an inappropriate gap can lead to toxicity or medicine interactions.
• Leaving an inappropriate gap can reduce therapeutic effect.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) can heat transdermal patches containing metal components and cause a small increase in body temperature:

• This can result in skin burns or drug toxicity.
• Fentanyl and buprenorphine patches are known to result in serious overdose.
• It can be difficult to accurately confirm which patches contain metal.

Advice for all transdermal patches during MRI:

• Remove the transdermal patch before the person enters the MRI scan room. Significant blood concentrations may exist for short periods because of the reservoir of medicine within the skin.
• Replace with a new patch straight after the scan. Follow our advice on before application and during application.
• Update records when the replacement patch is applied. Follow our advice under record and document.
• Continue to change the patch on the usual day and time e.g. if the patch is normally changed on a Monday and the scan is on Wednesday, replace it on Wednesday after the scan and change it as usual on Monday.

Record and document

Use a locally agreed method

The following written or electronic methods are suitable to record key information:

• Medication administration record (MAR) charts or hospital medication charts
• Electronic prescribing and administration systems (EPMA)
• Transdermal patch application record sheets or body maps.

Transdermal patch application record sheets or body maps do not replace the need to record administration on prescribing and administration systems (MAR chart, medication chart or EPMA).

Examples (non-SPS content):

• NHS Wales Aneurin Bevan University Health Board
  • Transdermal patch placement chart
  • 14 day patch rotation chart

Key information to record

• Date and time of application
• Site of application (e.g. upper right arm)
• Number of patches
• Frequency and interval between patch application
• Date and time of removal
• Brand of patch and strength

Patches containing controlled drugs

Follow local procedures for documentation in the controlled drug register during patch application and removal.

At transfer of care

Medication errors can occur with patches during the transition of care. To reduce the risk of errors do the following:

• Communicate the key information to record (listed above) when transferring people between settings.
• Provide a copy of records (including the transdermal patch sheet or body map).

Monitor

In addition to regular medicine specific monitoring, we recommend people using transdermal patches are monitored for the following.

Patch is in the correct position

We recommend to regularly check (e.g. every day) that the patch is in the correct position according to records. Document that the check has occurred using the locally agreed documentation.

Signs and symptoms of overdose

Be aware of signs and symptoms of toxicity from the medicine in the patch. Refer to information in the professional and patient literature on the Electronic Medicines Compendium (eMC) or provided with the packaging:

• Monitor the person for toxicity and seek medical attention immediately if overdose is suspected.
• Be aware that external heat and fever can increase the absorption of some medicines through the skin into the bloodstream and increased side-effects can occur.
• Remove patches before an MRI as there is a risk of medicine toxicity due to a possible small increase in body temperature.

It is recommended people using patches should avoid:

• Heat pads, electric blankets or hot water bottles
• Soaking in a hot bath, sauna or sunbathing for long periods of time.

Application site reactions

Patches can cause local reactions which present as contact dermatitis with erythema (redness of the skin), rash, vesicles (small fluid-filled sacs or blisters), burning, stinging or itching. This can be related to poor patch application technique.

Minimise risk

To reduce the risk of application site reactions:

• Ensure the manufacturer’s instructions have been correctly followed.
• Follow our advice on before application and at removal.

Our key advice is to:

• remove patches carefully to minimise skin irritation.
• ensure the skin is not broken, irritated or frail.
• rotate the site at each application.
• clean the irritated site with water.

Seek further advice

Discuss with the prescriber when:

• Local reactions persist. A decision to remove the patch should be done on a case-by-case basis.

If an allergic reaction is suspected to the ingredients or adhesive:

• Check if the person has known medicine, excipient or chemical allergies.
• Confirm the brand of the patch as alternative brands may be suitable.
• Document the suspected allergy in the person’s medical records.

Other national advice on using patches

MHRA Alerts

The MHRA has issued safety alerts for the following transdermal patches. All staff involved in administering these patches should be aware of the risks.

Fentanyl

In 2014, the MHRA  highlighted the risk of life threatening harm from accidental exposure of fentanyl patches.

Reports of preventable accidental transfer of fentanyl patches have continued in recent years. The MHRA provide advice and actions to reduce the risk of:

• Serious and fatal overdose of fentanyl patches
• Life-threatening and fatal opioid toxicity from accidental exposure.
• Harm, including fatalities, in opioid-naïve patients

Rivastigmine

Medication errors and inappropriate use of the rivastigmine transdermal patch have been reported, some of which resulted in overdose.

The MHRA advise patients and carers on the correct use of rivastigmine.

Patient Information

The following leaflets are helpful if people would like to know more about their medicines or if they are being discharged home on a patch.

• NHS Patient Leaflets on fentanyl and buprenorphine.

Manufacturers’ Patient Information Leaflets are available as:

• Paper copies inside the product packaging
• Electronically on the Electronic Medicines Compendium (eMC).

Acknowledgements

We are hugely grateful for input from NHS colleagues including pharmacists, technicians and nurses from the following sectors:

• Acute Trusts
• Care Homes
• Clinical Commissioning Groups
• Health and Justice
• Primary Care Networks

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