Group urges going metric to head off dosing mistakes.

Abstract

• A child receives a 5-fold overdose of antibiotics for 3 days after a pharmacist mistakenly labels a medication to specify a dose of 3.5 teaspoons instead of the prescribed dose of 3.5 mL. • Anursemisreadsaprescription that specifies “.5 mL” as 5 mL, resulting in a 10-fold overdose given to the patient. • A parent misunderstands instructions to administer 4 cc (4/5 teaspoon) and gives the child 4.5 teaspoons instead. These real and serious cases—one resulted in a child’s death—illustrate a small sampleof liquiddosingerrors thathavebeen reported to the Institute for Safe Medication Practices (ISMP). The ISMP has receivedat least 50 reports of just 1 typeof error, confusingmilliliterswith teaspoons.The reports provide a window into how easily nonstandardized dosing can compromise medicationsafetyandhavespurredapublicprivate effort to standardize liquid medication dosing for products obtained at community pharmacies. Daniel Budnitz, MD, MPH, director of the US Centers for Disease Control and Prevention’s (CDC’s) Medication Safety Program, said that about 3000 to 4000 children are treated in emergency departments each year as a result of medication errors by a caregiver. Poison control centers in the United States also field approximately 10 000 calls each year about dosing confusion, he said. Since 2008, the CDC has been working with a variety of stakeholders to prevent medication dosing errors through the Protect Initiative (http://1.usa.gov/1eIyG3G). ThegoalofProtect is toworkwithstakeholdersto institutestandardizeddosingpractices across sectors. Most hospitals already followmedicationdosing standards, such as using only metric measurements, as required for Joint Commission accreditation. The CDCworkedwith the US Food and Drug Administration and the Consumer Healthcare Products Association to develop voluntary guidelines that were published in 2011.Most over-the-counter products adhere to the guidelines, according to an analysis by Budnitz and colleagues (Budnitz DS. Pediatrics. 2014;133[2]:e283e290). Of 68products the teamexamined, 91% of the dosing directions and 62% of dosing devices followed guideline recommendations designed to prevent errors. Such recommendations specified, for example, including a dosing device with the medication, not using unusual units, adding zeroes before decimal points, and using dosing devices that are not substantially larger than the largest recommended dose of themedication. Budnitz explained that the basic approach is “simpler is better.” The CDC recommends using only milliliters as a measure for l iquid medications to avoid confusion between teaspoons and milliliters and avoiding relatively unfamiliarmeasures suchasdrams (aholdover fromapothecaries). The CDC wants the dosing device with the appropriate unit of measurement includedwith themedication to avoid caregivers using a kitchen spoonorother implement that uses a different unit of measurement. Further, the enclosed device should only have the recommended doses labeled on it tomake it even easier and safer to use. The ISMP’s recommendations, issued in 2011 (http://bit.ly/1me5sMB),aresimilar,but theorganizationgoesastep further thanthe CDC and advises that a patient’s weight should be expressed only in kilograms. Michael Cohen, RPh, MS, ScD, president of