Liquid medication dosing errors

BACKGROUND Our goal was to examine the following issues relevant to the use of liquid medications: (1) which liquid medication dosing devices are comm only owned and used; (2) the ability of potential patients to accurately me asure liquids using 3 different dosing devices; (3) their ability to correc tly interpret a variety of dosing instructions; and (4) their ability to co rrectly interpret a pediatric dosing chart. METHODS One hundred thirty volunteers from the waiting areas of 3 primary c are clinics in the St. Paul, Minnesota, area were interviewed. Participants were shown 7 liquid dosing devices and were asked which they had in their homes and which they had ever used, The participants were tested and scored on their ability to measure liquid medicines and interpret dosing instruct ions accurately. The total performance score was determined, with a maximum obtainable score of 11. RESULTS A household teaspoon was the device most frequently used for measur ing liquid medication. Women and participants with more education had highe r total performance scores. Common errors included misinterpreting instruct ions, confusing teaspoons and tablespoons on a medicine cup, and misreading a dosage charr when weight and age were discordant. CONCLUSIONS Clinicians need to be aware that many people continue to use in accurate devices for measuring liquid medication, such as household spoons. They should encourage the use of more accurate devices, particularly the o ral dosing syringe. Clinicians should always consider the possibility of a medication dosing error when faced with an apparent treatment failure.