Instructions for dosing of prescribed liquid medications need improvement

Abstract

Unintended overdosing of liquid medications in children has been associated with life-threatening and even fatal consequences. The Centers for Disease Control and Prevention began in 2008 to engage stakeholders in describing strategies to reduce unintentional overdose in children (the PROTECT initiative) and recommended one key initiative in 2012—to communicate, prescribe, and label liquid medication doses only in milliliters (mL). Prescribing or labeling by teaspoon or tablespoon dosing alone or along with mL dosing may incorrectly suggest to caregivers that the use of household tableware for dispensing medication is appropriate. In this issue of The Journal, pharmacists in Philadelphia analyzed healthcare professionals' (HCP) prescriptions and pharmacy-applied labels on 649 prescriptions filled for the top 10 liquid medications given to children in four Philadelphia community pharmacies during 3 months in early 2012. In essence, they learned that a multiprong, multipartner education (of HCPs, pharmacists and caregivers) and pharmacy policies are needed urgently to attain safe practices. Lack of HCPs' exclusive use of mL dosing, as well as pharmacist changes of mL dosing to teaspoon/tablespoon dosing or to include both measurement options, occurred frequently in the dispensing of medications studied. This study uncovers holes in our new healthcare patient safety net. Hospitals—accustomed to scrutinizing, changing, and applying universal medical staff policies, pharmacy policies, ordering policies, and prepopulating order sets—can implement new safety initiatives almost immediately. Education is important, but policies will be needed in outpatient settings (ie, pharmacies) to immediately protect children from unsafe behaviors in dosing and administering liquid medications. Article page 596▶ Communicating Doses of Pediatric Liquid Medicines to Parents/Caregivers: A Comparison of Written Dosing Directions on Prescriptions with Labels Applied by Dispensed PharmacyThe Journal of PediatricsVol. 164Issue 3PreviewTo identify and compare volumetric measures used by healthcare providers in communicating dosing instructions for pediatric liquid prescriptions to parents/caregivers. Full-Text PDF