Sometimes low tech solutions can save lives, too

I’m a pediatrician, so when I prescribe medications for my patients, I often have to give them liquid formulations. It’s not as easy, nor as precise, to dose liquids as pills or tablets. Is this a problem? Yes:

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.

METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.

This study looked at parents of children prescribed medications in an emergency department. Researchers wanted to find out how often there were errors in knowledge of prescribed doses or observed dose measurement. The results were not good.

Almost 40% of parents made an error when measuring out a correct dose. More than 40% of parents did not have proper knowledge of the prescribed dose. Additionally, 17% of parents used a non-standard instrument, meaning they used something like a plain old silverware teaspoon to measure out “a teaspoon”. Finally, parents who used units of tsp/tbsp as opposed to milliliter-only had twice the odds of making an error.

This is a fixable problem. First, we need to stop using old-school amounts like “teaspoon” and “tablespoon” to describe how much medication to give kids. We’d likely be much better off using the metric system, with measurements like milliliters. Second, we need to make dispensing dosing instruments that are metric-system only standard with liquid medications.

This may not be flashy or high-tech, but it’s likely to make a big difference.


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