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Reporting a Medication Error

Demonstration Devices Mixed Up with Real Devices

Published May 6, 2024

Medicine devices are sometimes needed to administer medicines. For example, inhalers are devices that are commonly used with asthma medicines to help get the medicine into the lungs. Pen injectors can be used for insulin (used to treat diabetes) and epinephrine (EpiPen) (used to treat allergic reactions). People who have never used the device need to know how to use it to give medicine to themselves or someone else. To practice using these devices, pharmacists and other healthcare providers may use demonstration devices (also known as “demo” or “training” devices). A demo device (Figure 1) looks similar to the actual medicine device, but it does not contain medicine or have a needle. Since the demo device looks like the actual device, this could confuse people.

Figure 1. The demo product (left) looks just like the actual product (right).

In one case, a pharmacy used demo albuterol inhalers to teach people how to use the inhaler to take their medicine. Unfortunately, some people were accidentally given the demo devices (without medicine) instead of the prescribed albuterol inhaler. The two products looked almost identical, which led to the mistake. Also, the demo product did not clearly state on the carton or the device that it should only be used for training. And, it even had a barcode, just like the actual medicine, for the pharmacy to scan before it was dispensed. Once the error was discovered, the pharmacy called all of the people who received the demo products, and they gave them the actual medicine device. None of the patients were harmed.

Figure 2. Demo devices do not contain medicine or needles. Words such as, “Demonstration Purposes Only,” “Trainer, For Practice Only” and “Does Not Contain Medication” should be on the product label.

Here's what you can do: If you or a family member use a medicine device, look at the carton and the device before use. Make sure it is the actual medicine. A demo product label might say, “Demonstration Purposes Only," “Does Not Contain Medication,” or “Trainer” (Figure 2). If you receive a demo device by mistake, do not use it. Go back to the pharmacy to return it and pick up your actual medicine. If your healthcare provider gives you a demo device to practice with, do not store it with your medicine. Only use the demonstration device to practice giving the medicine. If you do not need it anymore, throw it away.

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