From the June 28, 2007 issue
Over the years, nurses and pharmacists have reported that CATAPRES (clonidine) patches present problems because the manufacturer does not print the name of the drug or the strength on the patch itself. The patches are available in a variety of strengths and worn for a week at a time. Issues arise if the dose of a patch is changed, or if the patient requires multiple patches. In a hospital setting, in particular, there can be numerous caregivers interacting with a patient during the week; upon visualization, these caregivers can only determine that something is on the skin. They cannot determine the drug, the dose, or even whether it's a transdermal medication patch or some sort of band-aid. This sometimes sets people up to make errors. For example, a nurse could receive a new order for a clonidine patch or an oral dose, and not realize that the patient is already wearing a clonidine patch. Or, if the patient is wearing a clonidine patch along with another patch without a visible drug name and dose (e.g., LIDODERM [lidocaine], many contraceptive patches), the wrong patch might be removed and replaced with the same patch that remains on the patient. Thus, the patient would receive double the dose of one medication and none of the other. The cover (slit release liner) on the Catapres patch has also been mistaken for the actual drug patch and applied directly to the skin. We contacted the manufacturer, Boehringer Ingelheim, about this long-standing problem and learned that it has no immediate plans to print the drug name and dose on the patch. We were also told not to write on the patch directly, because it is not known if the volatiles contained in ink might affect delivery of the drug in some way. However, the manufacturer did note that the patch cover could be labeled and placed over the drug patch to protect it. There's also a code on each patch (see figure in the PDF version of the newsletter) that can be used to identify the strength: BI 33 designates a 0.3 mg patch, BI 32 is 0.2 mg, and BI 31 is a 0.1 mg patch. You might want to mention this in a future internal newsletter and attach a notation about the designation along with the inventory item so it appears on computer-generated medication administration records.