What’s New in the Patient Safety World
April 2015
Pediatric Dosing Unit Recommendations
The American Academy of Pediatrics has just issued a new Policy Statement on “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications” (AAP 2015). The statement strengthens some previous recommendations and includes many longer-standing recommendations for dosing safety.
First and foremost in the new policy statement is switching to sole use of metric dosing, i.e. strictly using milliliters for dosing of orally administered liquid medications in children and infants. Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, it emphasizes that the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”).
It also emphasizes several important recommendations that ISMP and other leading medication and patient safety organizations have made regarding good prescribing. Zeroes preceding decimals should be used when doses are less than one mL (eg. 0.5 mL) but trailing zeroes should never be used after decimal points. These help avoid 10-fold (or more) dosing errors. The concentration of the liquid medication should also be included on all prescriptions (eg. in mg/mL). Instructions on the prescription and label should also avoid easily misunderstood directions. For example, “daily” should always be used instead of “qd” (see our prior columns “Is Your ‘Do Not Use’ Abbreviations List Adequate?” and “The Impact of Abbreviations on Patient Safety” regarding use of “once daily” instead of “qd”).
It also recommends avoiding dosing to the hundredths of a milliliter. We discussed in our September 9, 2008 Patient Safety Tip of the Week “Less is More and Do You Really Need that Decimal?” the issue of how unnecessary digits following decimal points may lead to 10+ or 100+ dosing errors.
Dispensing devices are also critical. The statement recommends that pharmacies, hospitals, and healthcare centers distribute appropriate-volume milliliter-based dosing devices such as syringes. Another important point is that the syringe (or other dosing device) should not be significantly larger than the dose prescribed. It also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units.
Our November 2014 What’s New in the Patient Safety World column “Out-of-Hospital Pediatric Medication Errors” highlighted a study that was likely a major factor in the AAP coming out with the new policy statement. That study last year showed that parents’ measurement and dosing errors are common (Yin 2014). 39.4% of parents made an error in measurement of the intended dose and 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended and prescribed dose. Associations were greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors. The authors concluded that their findings support a milliliter-only standard to reduce medication errors.
So an important facet of avoiding pediatric medication errors is providing appropriate education to the parents at the time of prescribing (and dispensing). Health literacy and numeracy are factors important in contributing to medication errors (see our prior columns for June 2012 “Parents’ Math Ability Matters”, November 2014 “Out-of-Hospital Pediatric Medication Errors”, and January 13, 2015 “More on Numeracy”). Therefore, the AAP statement includes attention to use of tools and techniques such as teach-back, show-back, dose demonstration, pictures and drawings when educating the parents about the medication.
Recommendations for IT vendors and CPOE systems or other medication ordering systems include not only use of metric units but taking steps to prevent ordering of medications not using metric units.
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
July 2009 “NPSA Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
Septembrer 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
References:
AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015
http://pediatrics.aappublications.org/content/early/2015/03/25/peds.2015-0072.full.pdf
Yin HS, Dreyer BP, Ugboaja DC, et al. Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics 2014; 134(2): e354-e361; published ahead of print July 14, 2014
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