The death of a 6-year-old girl reinforces the importance of patient education when fentanyl transdermal patches are prescribed and dispensed. When the child complained of neck pain, her foster mother gave her an appropriate dose of ibuprofen. However, the foster mother also placed her leftover fentanyl patch on the child's neck to help treat the pain. The next day, the girl was found unconscious in bed. She was pronounced dead in the ED.

Some years earlier, the foster mother had been prescribed fentanyl transdermal patches to treat chronic pain after an accident. The patch she applied to the child was left from that prescription. She was charged with criminal gross negligence. This tragedy might have been avoided if she'd received more education about the safe use of the patches when they were first prescribed and dispensed.