1. Beal, Judy A. DNSc, RN, FNAP, FAAN

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Since 1975, concerns have been raised in pediatric research literature around the problem of medication errors in outpatient pediatrics. A recently published study by a team from NYU Medical School (Yin et al., 2016) received significant press coverage. Yin et al. (2016) concluded that liquid medication should be administered by an oral syringe that is metric-based only. This study is one of an extensive program of research dating back to 2007 when Yin et al. first published on the relationship of caregiver health literacy with parental lack of knowledge on how to administer and calculate weight-based dosing (Yin, Dreyer, Foltin, van Schaick, & Mendelsohn, 2007). The team has since had further data published on the role of provider counseling to prevent dosing errors and use of pictograms to reduce errors and improve adherence among caregivers. In this recent study, Yin et al. (2016) found that in a sample of 2,100 English- or Spanish-speaking parents of children 8 years or less from three urban pediatric clinics, 84.4% made one or more dosing error. Two thirds of medication errors were overdoses and 21% of the parents measured two to four times more than the intended dose. A four-fold increase in errors was seen with cups versus syringes.


The American Association of Poison Control Centers reported in 2013, nearly 80% of all calls and medication errors occurred in children <=12 years and 85% of these errors were attributable to misunderstanding units of measurement on dispensing cups (Mowry, Spyker, Cantilena, McMillan, & Ford, 2014). Schillie, Shehab, Thomas, and Budnitz (2009) reported that administration of an incorrect dose was the most common reason for unintended poisoning in young children for the more than 70,000 pediatric emergency room visits annually due to unintentional medication overdoses.


Until 2011, there were no standard guidelines for labeling, packaging, or dosing instruments provided for liquid medication administration (American Academy of Pediatrics [AAP], 2015). In 2011, the US Food and Drug Administration (US Department of Health and Human Services, Food and Drug Administration, & Center for Drug Evaluation and Research, 2011) finalized recommendations to the pharmaceutical industry that addressed accurate liquid medication administration with clear directions on metric dosing. Subsequently, AAP released its recommendations to use only metric measurement on prescriptions, medication labels, and dosing instruments. They also recommended medications should never be administered by a kitchen spoon, rather by metric-dosing devices such as cups and syringes (AAP).


Berrier (2016) offers an excellent summary of strategies to promote safe pediatric outpatient liquid medication administration: eliminating use of teaspoons and tablespoons for administration; using milliliter measurements only; rounding all dosing instructions to the nearest 0.1, 0.5, or 1 mL; and providing patient education and advanced counseling (demonstration, return demonstrations, and use of pictograms). Picture-based instruction is especially warranted due to the strong relationship between low health literacy and parental lack of knowledge (Yin et al., 2007). Education and counseling can effectively decrease medication errors. Nurses play an essential role in education and prevention of this widespread pediatric problem.




American Academy of Pediatrics. (2015). Metric units and the preferred dosing of orally administered liquid medications (Policy Statement). Pediatrics, 135(4), 784-787. Retrieved from [Context Link]


Berrier K. (2016). Medication errors in outpatient pediatrics. MCN. The American Journal of Maternal Child Nursing, 41(5), 280-286. doi:10.1097/NMC.0000000000000261 [Context Link]


Mowry J. B., Spyker D. A., Cantilena L. R., McMillan N., Ford M. (2014). 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clinical Toxicology, 52(10), 1032-1283. doi:10.3109/15563650.2014.987397 [Context Link]


Schillie S. F., Shehab N., Thomas K. E., Budnitz D. S. (2009). Medication overdoses leading to emergency department visits among children. American Journal of Preventative Medicine, 37(3), 181-187. doi:10.1016/j.amepre.2009.05.018 [Context Link]


US Department of Health and Human Services, Food and Drug Administration, & Center for Drug Evaluation and Research. (2011). Guidance for industry: Dosage delivery devices for orally ingested OTC liquid drug products. Retrieved from [Context Link]


Yin H. S., Dreyer B. P., Foltin G., van Schaick L., Mendelsohn A. L. (2007). Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambulatory Pediatrics, 7(4), 292-298. doi:10.1016/j.ambp.2007.04.004 [Context Link]


Yin H. S., Parker R. M., Sanders L. M., Dreyer B. P., Mendelsohn A. L., Bailey S., ..., Wolf M. S. (2016). Liquid medication errors and dosing tools: A randomized controlled experiment. Pediatrics, 138(4), 1-13. doi:10.1542/peds.2016-0357 [Context Link]