Preventing common medication dosage errors

Medication dosing mistakes for children are common when parents encounter various measurements terms used interchangeably by health care providers or on the bottle’s label, according to a study released online today from Pediatrics.

Medication errors from a mix up of measurement terms – such as milliliter, teaspoon and tablespoon – contributes to more than 10,000 poison center calls each year. Parents or caregivers may not remember their child’s prescribed dose or may not know how to measure the dose correctly.

In the study, researchers followed almost 300 parents from two pediatric emergency departments when a child was prescribed a daily oral liquid mediation for 14 days or more. They collected information from chart reviews, phone interviews and in-person observations.

They found that 39.4 percent of parents incorrectly measured the dose they intended, and ultimately 41.1 percent made an error in measuring what their doctor had prescribed.

Parents who used teaspoon or tablespoon units to describe their child's dose of liquid medicine had twice the odds of making a mistake in measuring the intended dose compared to parents who used milliliter-only units. Parents who described their dose using teaspoons or tablespoons were more likely to use a kitchen spoon to dose, rather than a standardized instrument like an oral syringe, dropper, or cup. Even those who used standardized instruments were still more likely to make a dosing error if they reported their child's dose using teaspoon or tablespoon units.

Study authors and organizations like the American Academy of Pediatrics, Centers for Disease Control and Prevention, and the Institute for Safe Medication Practices suggest adopting a milliliter-only unit of measurement could reduce confusion and decrease medication errors, especially for parents with low health literacy or limited English proficiency.

For now, regular blog contributor Hazel Guinto-Ocampo, M.D. says we should keep the following in mind when giving children liquid medication:

  • Most liquid medications are formulated so that the most common pediatric weight-based dosages can be conveniently given by teaspoons or portions thereof such as full; half; or one and a half.  
  • One teaspoon makes five milliliters. One tablespoon makes 15 millimeters. However, household teaspoons and tablespoons come in all shapes and sizes and hold a variable volume of liquid. 
  • The best practice would be for prescribers to write the dose in milliliters, and for parents and caregivers to be given an oral syringe by the prescriber or pharmacist. The prescriber, nurse, or pharmacist can also show how much to give, or even mark the syringe with the appropriate dose. (You can ask if the prescriber can provide an oral syringe or purchase one.)
  • It is easy to administer liquid medications orally using a syringe; there is less chance of medication spillage compared to using a teaspoon.

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