PhotoMedication errors injure more than 1 million people every year and in some cases, taking too much or too little of the wrong medicine can result in death.

A study by the National Library of Medicine, part of the National Institutes of Health (NIH), specifically looked at dosage errors, identifying 200 prescribing errors with potentially adverse outcomes involving dosage equations.

It found that errors most commonly involved children and the drugs most likely to be in error were antibiotics. In the study 42% of errors were considered to put the patient at risk for a serious or severe outcome that could have been avoided.

Because dosage errors so often involve children the American Academy of Pediatrics (AAP) is trying to raise awareness, urging parents not to ever administer liquid medication using a spoon. Though most parents probably got their medicine from a spoon as children, AAP says spoons are for cereal, not medicine.

No spoons

“Spoons come in many different sizes and are not precise enough to measure a child’s medication,” said pediatrician Ian Paul, lead author of the AAP policy statement.

If not a spoon, then what? AAP recommends something that measures liquid medicine in metric units. It's the only way to be sure you are administering the precise dosage.

“For infants and toddlers, a small error – especially if repeated for multiple doses – can quickly become toxic,” Paul said.

Every year more than 70,000 children are rushed to the ER because of accidental medication overdoses. AAP says sometimes a caregiver will see the dosage instructions as milliliters and mistake that for teaspoons. Often they use the wrong kind of measuring device and as a result, the child can get 2 or 3 times the recommended dose.

“One tablespoon generally equals 3 teaspoons,” Paul said. “If a parent uses the wrong size spoon repeatedly, this could easily lead to toxic doses.”

Kids don't take pills

Most children's medication comes in liquid form because it is easier to administer. Children often have trouble swallowing a pill. But a pill comes pre-measured, liquid generally does not.

Adding to the confusion, AAP says common over-the-counter liquid medications for children often have metric dosing instructions on the label but include a measuring device marked in teaspoons, or vice versa.

This AAP concern about dosage errors is not new. The organization previously testified before the Food and Drug Administration (FDA) urging metric-only labeling and dosing. It has updated its 2015 policy statement to make the following recommendations:

  • Standard language should be adopted, including mL as the only appropriate abbreviation for milliliters. Liquid medications should be dosed to the nearest 0.1, 0.5, or 1 mL.
  • How often a dose is needed should be clearly stated on the label. Common language like “daily” should be used rather than medical abbreviations like “qd,” which could be misinterpreted as “qid,” which in the past has been a common way for doctors to describe dosing four times daily.
  • Pediatricians should review mL-based doses with families when they are prescribed.
  • Dosing devices should not have extra markings that can be confusing, and should not be significantly larger than the dose described on the label, to avoid two-fold dosing errors.
  • Manufacturers should eliminate labeling, instructions and dosing devices that contain units other than metric units.

“We are calling for a simple, universally recognized standard that will influence how doctors write prescriptions, how pharmacists dispense liquid medications and dosing cups, and how manufacturers print labels on their products,” Paul said.


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