1. Shastay, Ann MSN, RN, AOCN

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Auvi-Q post injection ticking sound. The AUVI-Q auto-injector (EPINEPHrine injection) uses digital voice instructions to "talk" people through the injection process (Figure 1). The device has LED light cues that flash green during injection and red after the device has been used. Prior to injection, Auvi-Q must be removed from its case and the needle guard must be pulled off (view the Auvi-Q demonstration at: The device will make a distinct click and hiss sound when activated. According to the package insert, the base that houses the needle will lock in place after injection so it can't be reused. The voice instruction system will continue to remind the user that the Auvi-Q has been used, and its LED lights will continue to blink red until the cover is put back on or until the battery eventually runs out. If the cover is not replaced on the device, the electronic voice speaker makes a "ticking" sound as the battery drains. This sound might alarm someone who thinks the ticking noise is associated with a possible calamitous event. Emergency department staff alerted us to this recently after the family of a patient who used an Auvi-Q auto-injector brought it in without the case. Staff later heard a ticking sound coming from a needle disposal box where the device had been discarded. Remind staff that the cover needs to be replaced or the device will emit a ticking sound as the battery dies. We have notified the companies about this sound, which may cause staff to call security if the source of the ticking noise is not realized.

Figure 1 - Click to enlarge in new windowFigure 1. Auvi-Q must be replaced in its case prior to disposal to prevent ticking sounds as the battery dies

Angeliq-not a birth control pill! ANGELIQ (drospirenone, estradiol) is a hormone-based medicine used to relieve the symptoms of menopause. Unfortunately, we're aware of errors where it was prescribed improperly as an oral contraceptive. Our sister organization, ISMP Canada, recently received two reports. In each case, a physician provided a woman with samples of Angeliq to take as birth control. The mistakes were discovered when the women took prescriptions for further supplies of Angeliq to their pharmacies and referred to them as "birth control pills." Angeliq has a number of similarities to birth control pills that might have played a role in the mix-up. The labeling and packaging is similar in design to birth control pills. It's available as a 28-day blister pack. "Angeliq" also sounds like a woman's name-many birth control pills also have female-sounding names. In addition, neither the outer nor the inner package of the Angeliq sample pack has any information that the medicine is to be used for symptoms of menopause, and the hormones contained in Angeliq appear similar to the ingredients in birth control pills: a progestin and estrogen component. However, the dose of progestin in Angeliq is less than that used in birth control pills, and the potency of the estrogen used in Angeliq is also different from the potency used in birth control pills, pregnancy is possible. That's exactly what happened to a woman we heard from recently through our consumer error-reporting program ( Her doctor had given her Angeliq for birth control, and she believed she was pregnant. Individuals who might prescribe oral contraceptives should be warned of this risk. Ideally, consider a pop-up alert for prescriber order entry systems.


Diastat AcuDial requires setting and locking of the dose. The DIASTAT ACUDIAL (diazepam rectal gel) delivery system is available for rectal administration to manage selected refractory epilepsy patients who are on stable regimens of antiepileptic drugs and also require intermittent use of diazepam to control bouts of increased seizure activity. The product is available in 10 mg or 20 mg rectal syringes designed to deliver minimum dosages of 5 mg or 12.5 mg, respectively, with dosage increments of 2.5 mg up to a maximum of either 10 mg or 20 mg. (There is also a 2.5 mg syringe available for pediatrics.) There are two unlocked rectal syringes per package. Since the introduction of the device, a number of errors have occurred because the device was not properly dialed and locked prior to administration. This led to administering too much medication. Some of these errors have resulted in respiratory depression requiring emergency intervention. Before the product is dispensed, syringes must be dialed, set, and locked to the prescribed dose by the pharmacist, even when the maximum dose is prescribed. Once set and locked, the prescribed dose will appear in the dose display window, and the locking ring, designated with a green "ready" band, will be engaged. This helps prevent the wrong dose or an overdose from being administered by the caregiver. Recently, we received a report from a consumer who gave her adult daughter 20 mg instead of 15 mg. Pharmacists need to lock the syringes and educate patients and caregivers about the proper use of the device, including confirming that: the prescribed dose is visible in the display window; the green ready band is visible; and the smaller rectal tip size is used if the patient is a child.


Issues with Medtronic MiniMed Revel insulin pump. An endocrinology practice was asked to see a patient having low blood glucose levels while receiving insulin through a Medtronic MiniMed Revel portable infusion pump. The pump allows information to be downloaded and it showed that the patient was getting boluses during the night. The patient denied administering any doses. However, the data showed that up to 10 units at a time were being administered. Medtronic told us it has had rare reports of people accidently rolling over onto the pump at night and activating a bolus. A patient would have to activate 2 buttons for the pump to actually deliver a dose, which is why this is a rare occurrence. There is a feature to lock out the keypad so that this doesn't happen. The patient was shown how to use this and the problem was resolved. A second patient also had mysteriously low blood glucose levels while using the Revel pump. In this case, it had nothing to do with accidentally activating the bolus system. Instead, this involved the patient entering erroneous information into pump software. The pump has a bolus dosing "wizard" that allows patients to enter their blood glucose and the amount of carbohydrate grams they've eaten. By mistake the patient was accidentally entering the measured blood glucose into the carbohydrate field instead of the number of carbohydrates eaten. For example, 220 was entered in the carbohydrate field instead of 60 grams. The safest way to administer a bolus dose is to use the glucose meter that goes with the pump. This automatically communicates the glucose level information to the pump so the user does not need to manually enter the results. In this case, the patient's insurance did not cover the test strips for this pump, so the patient was using his own glucose meter and entering the results manually. Also, the pump will warn you when an entry is outside the usual range, but the warning can be overridden. In this case, the patient could not see the pump screens clearly because the backlight lighting is quite dim. Medtronic told us there is no way to make the light any brighter. They agreed to pass on the information from this report internally to consider whether any enhancements were needed to improve the device.