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Reporting a Medication Error

Confusion with Catapress-TTS Patches

Reviewed August 7, 2023

Catapres-TTS (transdermal therapeutic system) patches contain the medicine clonidine, which is used to treat high blood pressure. The patch is applied to the skin where it slowly releases the medicine into the body over a specific period of time.

Catapres-TTS carton indicating the package contains 4 medicine patches and 4 adhesive covers.
Figure 1. The pouch for the adhesive cover displays a warning statement indicating the cover does not contain medicine.

Once a week the patch needs to be removed and replaced with a new one. Confusion can occur because of the way the patch is supplied by the manufacturer. The medicine is on a tan, square, adhesive patch. However, it is packaged with a white, round, adhesive patch cover to use over the tan patch. This white cover helps keep the tan medicine patch in place, but is not necessary to use. There is a warning on the pouch that contains the white cover patch saying it does not contain medicine (Figure 1). However, if the warning is missed, the white cover patch may be applied by itself without the tan medicine patch underneath. Therefore, no medicine will be given. 

This type of error actually happened in a nursing home. For 2 weeks in a row, a nurse only applied the white cover patch to a patient, thinking it contained the medicine. It wasn’t until the third week when a different nurse was caring for the woman that the mistake was recognized. The nurse noticed extra tan medicine patches in the woman’s medicine drawer. When she removed the white cover patch from the woman’s arm, a tan medicine patch was not underneath, which was why there were extra tan patches in the drawer.

Here’s what you can do: Make sure you understand how to use medicine patches correctly. Talk to your pharmacist when you pick up your prescription. Ask questions if you are not sure how or where to apply the patch. Know how often the patch needs to be changed. Read the medicine pamphlet that is given to you when you pick up your prescription. If you experience any side effects, contact your healthcare provider.

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