Preventing Dosage Errors with Diastat AcuDial

The Institute for Safe Medication Practices recently warned about potentially fatal dosing errors when using Diastat AcuDial. Diastat (diazepam rectal gel) is used to treat epileptic seizures, and it has been available for the past year or so in the AcuDial form. Each AcuDial package contains two pre-filled rectal syringes.

The prescribed patient dose must be dialed on the syringe and locked in place by the pharmacist prior to dispensing. ISMP notes that a number of errors have been reported because the device wasn't properly dialed and locked. In one case a young boy was prescribed a low dose of Diastat AcuDial. The pharmacy dispensed an unlocked 10 mg rectal syringe, and the parents administered the entire contents to the child. He developed respiratory depression and required emergency treatment.

One way to help prevent situations like this is to educate patients and caregivers about how to use the device. They should know the prescribed dose, confirm that it shows in the display window, and check that green "ready" band is visible.

But the most important safeguard is for the pharmacist to be sure that the prescribed dose has been dialed and locked for both syringes in the pack before dispensing. Here's how to do that:

• First, remove a Diastat syringe from the case, holding the barrel vertically so that the cap is facing downward. Be sure not to remove the cap.

• Second, grasp the cap firmly with your other hand and turn it to adjust the dose.

• Third, confirm that the correct dose shows in the window on the syringe.

• And fourth, lock the dose by grasping the locking ring and pushing it upward to lock both sides of the ring. The green "ready" band is now exposed, showing that the dose has been locked.

Be sure to repeat this procedure for the second syringe in the pack before dispensing.

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Tags:

• Diastat
• AcuDial
• FDA
• Epileptic
• Seizures
• Patient
• Safety
• Death