Fentanyl Overdose Due to Medical Documentation Error


This case involves a fifty-five-year-old female cancer patient who suffered from numerous complications. She remained in good spirits, however, and had the energy to resume near normal activities with sufficient pain medication. She presented to the ER with complaints of severe leg pain and was treated by various physicians who were managing her acute pain. The patient died during the overnight hospital stay. It appears that the cause of death was an overdose of Fentanyl that was ordered and issued at several orders of magnitude above the accepted adult loading dose.

Question(s) For Expert Witness

  • 1. What are your initial thoughts on the case?

Expert Witness Response E-000365

A number of fatal Fentanyl overdoses have been directly tied to the drug over the past few years. In particular, manufacturers of time-release Fentanyl patches have come under scrutiny for defective products. While the Fentanyl contained in the patches was safe, a malfunction of the patches caused an excessive amount of Fentanyl to leak and become absorbed by patients, resulting in life-threatening side effects and death. Regardless, Fentanyl is considered the safest opioid medication on the market, as well as the least physically harmful to the body, especially with long-term or life-term use. In this case, it would be considered a breach in care if the patient was prescribed a lethal dose that was not picked up by the pharmacy or nursing staff before being administered.

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