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We represent a lady who has experienced brain damage as the result of inappropriate prescription of a Durogesic Patch. She had one day surgery and was sent home wearing a Durogesic Patch. The manufacturer’s warns against using the Durogesic Patch unless the patient is under supervision. Neither the patient not the family were warned of the need to monitor her or that this was an off label use of the Durogesic Patch. Twenty four hours later she was unconscious. During the night the patch had caused a reduction in her heart rate which impaired the oxygen flow to her brain. Informed consent may have prevented this tragedy.

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