Published February 17, 2025
It is not unusual to wake up in the middle of the night when you don’t feel well. You may have an upset stomach or a headache. If that happens, you may go to your medicine cabinet to take medicine that will treat your symptoms so you can go back to sleep. If you have been sick, you may keep the medicine close by, on your nightstand or in the drawer, so you can take it without getting out of bed. However, it is important to turn on the light to see what you are taking and that you take the medicine correctly. Unfortunately, we have received reports of errors that were made when the lights were not turned on.
A man was awakened by a toothache in the middle of the night. Without turning on the lights, he pulled out and applied what he thought was a spray of pain reliever for his toothache. Afterwards, he did not rinse his mouth. In the morning, he realized he had actually used Lamisil AT pump spray in his mouth. Lamisil AT(terbinafine hydrochloride 1%) is used for fungal infections on the skin such as athlete’s foot. It should never be placed in the mouth or swallowed.
A woman accidentally injected Aimovig (erenumab) into her thumb instead of her thigh. Aimovig comes in an autoinjector and is injected once every month to prevent migraine headaches. The woman tried to give herself an injection in the dark and mistakenly pressed the autoinjector into her thigh upside down after removing the cap over the needle safety guard. The shape of the start button at the top of the autoinjector and the needle safety guard at the bottom of the autoinjector felt similar (Figure 1). She then pressed what she thought was the autoinjector start button but was actually the needle safety guard. Thus, the needle safety guard was pressed into her thumb, rather than her thigh, exposing the needle and injecting the medicine into her thumb.
Here’s what you can do: All medicines should be taken with the lights on to allow visibility of the product label and visual inspection of the actual medicine. Many medicines are packaged in similar containers (e.g., eye and ear drops, spray bottles), so it is important to read the label to ensure you are using the right medicine. In addition, anytime an injection needs to be administered, appropriate steps should be taken to ensure the injection site is clean and the needle or autoinjector are not contaminated. For example, the Aimovig autoinjector should be inspected prior to use for cracks and to make sure the medicine in the window of the autoinjector is clear and colorless to slightly yellow. The Aimovig injection takes about 15 seconds, and when completed, the window turns from clear to yellow. Furthermore, despite similarities in the shape of the start button and needle safety guard, the autoinjector is much less likely to be pressed into the skin upside down if the lights are on.
