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PSNet: Patient Safety Network
Journal Article

Liquid medication errors and dosing tools: a randomized controlled experiment.

Yin S, Parker RM, Sanders LM, et al. Pediatrics. 2016;138.

Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.