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Reporting a Medication Error

Two Too Many Medicine Patches!

Published March 25, 2024

Lidocaine is a medicine used to numb an area of the body to decrease the amount of pain that is felt. It can be purchased over-the-counter(OTC) as creams, ointments, and patches. These products are generally safe to use and can provide temporary help for muscle and joint pains, such as back, neck, or shoulder pain. A healthcare provider can also prescribe higher strengths of lidocaine if OTC products are not helpful. However, it is important to use the lidocaine as ordered by your healthcare provider.

In one case, a doctor prescribed lidocaine 5% patches for an older person. The instructions on the prescription said, "apply one patch daily, for 12 hours on and then off for 12 hours." The pharmacy dispensed a box of lidocaine patches with a pharmacy label on the outer carton with the doctor’s instructions. The box contained 30 patches that were each sealed in an envelope. When the person took a patch from the box, the instructions on the envelope said, “apply up to three patches” (Figure 1). So, the person used three patches at one time instead of following the doctor’s instructions that were on the pharmacy label. Using too much lidocaine is not safe, especially for an older person. If too much is used for a long time, it can cause a decreased heart rate and low blood pressure that can lead to seizures and heart problems. So, it is important to use the medicine as prescribed.

Figure 1. Instructions on the envelope of a lidocaine patch say, “apply up to three patches.” These instructions may be different than what was prescribed by your doctor.

Here's what you can do: If you or a loved one is prescribed lidocaine 5% patches, always follow the directions on the pharmacy label attached to the box. Do not follow the directions on the actual product. When lidocaine 5% patches are prescribed, make sure you understand how to use them. Ask to speak to the pharmacist when picking up your prescription. Ask the pharmacist to show you where the instructions are on the label. Ask them to highlight or circle this information so it is more visible.

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