A 68-year-old man with metastatic lung cancer was treated in the emergency room for shortness of breath and back pain. The physician meant to prescribe a fentanyl dermal patch to relieve his pain. Mistakenly, the patient was prescribed intravenous fentanyl, which is used for sedation. MedAware identified the mistake and the order was promptly canceled.

If given to non-ventilated patients, intravenous fentanyl may cause severe respiratory depression and even death.