Medication Safety Tips
Featured Resources
About UsReporting Medication ErrorsContact Us
Brought to you by
Left Chevron
Back
Left Chevron
Reporting a Medication Error

Confusion with Catapress-TTS Patches

Reviewed August 7, 2023 (revised November 5, 2024)

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.

Figure 2. 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. 

Catapres-TTS medicine patches and adhesive covers come in a carton that contains four of each (Figure 2). However, in hospitals or long-term care facilities, the medicine patches and the covers are not usually provided in the carton. So, the pharmacist dispensing the patch or the nurse administering the patch may not realize that only the tan patch contains the medicine and an error can occur.

This is exactly what 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.

Figure 3. This is an example of a graphic description of how to apply the medicine patch and adhesive cover.

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 receive a carton (Figure 2) from your pharmacy, look for the package insert that describes how to use the medicine. The graphic in Figure 3 is an example of instructions shown on a package insert showing how to apply the medicine patch and the adhesive cover. If you experience any side effects, contact your healthcare provider.

‍

More Safety Articles

Dramamine brand name will confuse

The brand name Dramamine is the latest example of a well known, over-the-counter (OTC) medicine name being recycled for use in products that contain a different medicine or ingredients that differ from those in the original product. The original Dramamine (regular or chewable) contains 50 mg of dimenhydrinate (Figure 1). But there is now a Dramamine that contains a different medicine called meclizine 25 mg per tablet (Figure 2). And another product, Dramamine Non-Drowsy Naturals, does not contain a drug at all—it’s a supplement that only contains ginger root (Figure 3).

Learn More

Humatrope Medicine Cartridges and the HumatroPen Size Must Be a Match!

Learn More

Looks Can Be Deceiving!

Boric acid suppositories are sometimes used to treat chronic vaginal infections when traditional treatments have failed. Vaginal infections are typically treated with antibiotics, such as metronidazole. For some women, the infection comes back right away. When this happens, some doctors will recommend trying boric acid suppositories.

Learn More

A documented allergy overlooked

A doctor prescribed Donnatal (hyoscyamine, atropine, scopolamine, and phenobarbital) for a man who was allergic to one of its ingredients, phenobarbital. Donnatal is used to relax the muscles in the bladder and intestines and to reduce stomach acid. The community pharmacy’s computer system issued a warning about the allergy, but the pharmacist missed seeing the message while entering the prescription into the computer. The doctor also overlooked the allergy even though it was documented in the patient’s chart. The error was discovered by the man while reading the pharmacy provided consumer medication information leaflet, which listed phenobarbital as one of the ingredients. The man did not take the Donnatal.

Learn More