Just Added!

New Videos with Amal Mattu, MD

Watch NowGo

Parents make serious dosing errors with liquid meds

November 9, 2016

Short Attention Span Summary

Parents make serious dosing mistakes
84% of parents made dosing errors when asked to pour various sample doses in this RCT. Of the errors, 21% would have resulted in a double dose!  This is scary.  Almost every parent in this study could not draw up a dose of liquid medicine properly.  Sheesh!  Thank heavens they were only asked to draw up the doses in this study, not give them.

Spoon Feed
Keep it simple.  Give dosing syringes vs. cups with mL-only markings (not teaspoons) to reduce pediatric dosing errors.


Pediatrics. 2016 Sep 12. pii: e20160357. [Epub ahead of print]

Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment.

Yin HS1, Parker RM2, Sanders LM3, Dreyer BP4, Mendelsohn AL4, Bailey S5, Patel DA6, Jimenez JJ4, Kim KA7, Jacobson K8, Hedlund L6, Smith MC3, Maness Harris L4, McFadden T9, Wolf MS6.

Author information: 

  • 1Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York; Department of Population Health, NYU School of Medicine, New York, New York; yinh02@med.nyu.edu.
  • 2Department of Medicine.
  • 3Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California;
  • 4Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York;
  • 5Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina;
  • 6Division of General Internal Medicine and Geriatrics, and.
  • 7Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
  • 8Rollins School of Public Health, and.
  • 9Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;



Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language.


Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ≤8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose).


A total of 84.4% of parents made ≥1 dosing error (21.0% ≥1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4).


Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

Copyright © 2016 by the American Academy of Pediatrics.

PMID: 27621414 [PubMed – as supplied by publisher

What are your thoughts?