What’s New in the Patient Safety World

September 2015

Alert: Use Only Medication Dosing Cups with mL Measurements

 

 

In our April 2015 What’s New in the Patient Safety World column “Pediatric Dosing Unit Recommendations” we discussed the American Academy of Pediatrics new Policy Statement on “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications” (AAP 2015). That new policy statement recommends 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”). 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.

 

Several other organizations have concurred with these recommendation and it should not just apply to pediatric patients.

 

Now a new national alert has been issued that recommends hospitals replace medication dosage cups that use units other than mL (NAN 2015). This follows reporting of a fatal event to the ISMP National Medication Errors Reporting Program in which a nurse confused two dosing scales that appear on a plastic oral liquid dosing cup. In that event drams were confused with mL, resulting in a fatal overdose of morphine.

 

Unfortunately, such cups are still available and it’s possible they will be found in your healthcare facility. The alert recommends that in their place you use available oral syringes that measure only in mL whenever possible. If a dosing cup must be used, ideally it should allow measurement in mL only.

 

 

 

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

 

 

NAN (National Alert Network). Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. NAN 2015; June 30, 2015

http://www.ismp.org/NAN/files/NAN-20150630.pdf

 

 

 

 

 

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