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

Lock in the dose of Diastat AcuDial

90c57ca8306bf148ef75c82407e738af MPeople who experience seizure activity (epilepsy) often take anti-seizure medicine to control the condition. However, sometimes additional medicine may be needed to control bouts of increased seizure activity (cluster seizures or breakthrough seizures). The Diastat AcuDial rectal administration system contains the medicine diazepam, rectal gel, to manage these breakthrough seizures. The product is available in a 10 mg rectal syringe designed to deliver a minimum dose of 5 mg, or a 20 mg rectal syringe designed to deliver a minimum dose of 12.5 mg. Both syringes allow for the dose to be increased by 2.5 mg up to a maximum of either 10 mg or 20 mg, respectively. (There is a 2.5 mg syringe for pediatrics.)

Before the product is dispensed, the pharmacist must dial, set, and lock in the prescribed dose (Figure 1). Once set and locked, the dialed dose will appear in the dose display window, and the locking ring, designated with a green “ready” band, will be in place. This helps prevent the wrong dose from being administered. diastat instructions

Since the introduction of the device, errors have occurred because the device was not properly dialed to the intended dose and locked by the pharmacy. Thus, too much medicine was given. An event was reported by a woman who gave her adult daughter 20 mg of the medication instead of 15 mg because the syringe was not locked by the pharmacist to deliver just the 15 mg dose.

In another event, a pharmacy dispensed an unlocked 10 mg Diastat Acudial rectal syringe to parents of a small child. The parents were new to the device and not educated that the dose needed to be locked. They administered the entire contents of the syringe to their son, who then developed respiratory depression requiring transport to the emergency room. Thankfully, the child recovered.

Here’s what you can do:

When picking up a prescription at the pharmacy, do the following:

✔ Ask to speak with the pharmacist.

✔ Open up the package and ask the pharmacist to make sure it is locked in place at the prescribed dose.

✔ Look at the display window to verify the dose and confirm that the green ready band is visible.

✔ Because 2 DIASTAT AcuDial delivery systems are packaged in a Twin Pack (with each prescription) be sure to double-check both syringes.

✔ If you are unsure how to give the medicine, ask the pharmacist to explain the procedure.

✔ Review any handouts or educational materials provided by the pharmacist.

More Safety Articles

Parents Staying with Their Hospitalized Child Can Help Detect Some Errors—But May Contribute to Others

Today, parents can often visit and stay with their sick, hospitalized child whenever they want. Many parents take advantage of this and remain with their child as much as possible, getting more involved in their child’s care. For an ill child, this can be comforting and provide an important emotional benefit, which might lead to faster healing as well as long-term behavioral benefits.1 For the parents, this can lead to less stress, anxiety, and sadness. 1

Learn More

Zantac Reborn

Learn More

Simple packaging change can reduce Rx drug diversion

Our organization often hears from consumers who report the quantity of medicine they receive from the pharmacy is less than the amount prescribed by their physician. For example, we recently received a report from a young patient who had dental surgery and received a prescription for the narcotic painkiller Lortab (hydrocodone and acetaminophen). On the prescription the dentist wrote for 24 pills to be dispensed. The patient’s mother had the prescription filled at a local pharmacy. When she returned home she counted only 21 pills. The mother called the pharmacy because she wanted to make sure the pharmacist was aware that a mistake had been made in the count. But the pharmacist became defensive, even suggesting that the woman’s daughter must have taken the pills without her knowledge.

Learn More

Adverse effects of numbing medications for teething in babies

Many parents like to rub numbing medications on their baby’s gums to treat the discomfort of teething. Products for this purpose, called topical anesthetics, are available for purchase over the counter (OTC). Examples include Anbesol and Orajel. There are also prescription products (e.g., viscous lidocaine) that doctors sometimes recommend. However, because of safety concerns, we do not recommend that babies receive medicines containing topical anesthetics.

Learn More