Say Goodbye to Confusing Ratio Expressions

Abstract

More than a decade ago, the Institute for Safe Medication Practices (ISMP) reported a number of serious safety events associated with the use of medications with doses displayed as ratio expressions. At that time, in 2005, there had already been more than 75 reports in the ISMP database dating back at least 10 years. 1 Paparella S Fatal confusion with epinephrine: 1:1,000 is NOT 1:10,000. J Emerg Nurs. 2005; 31: 86-88 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Unfortunately, wrong dose/wrong strength errors have continued to be common, and alarmingly, they include medications frequently used in emergency departments or procedural settings such as calcium, epinephrine, lidocaine, magnesium sulfate, isoproterenol, neostigmine, and sodium bicarbonate. Through continued review and analysis of this issue, ISMP has repeatedly heard from practitioners who report confusion when the drug label expresses the drug strength using percentages (eg, lidocaine 1%) or when ratio expressions are included (eg, isoproterenol 1:5,000). These serious and sometimes even fatal errors did not occur because practitioners were uncaring or irresponsible; instead, these events were often associated with confusion about the drug’s concentration. Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.*ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.