Good Idea, Bad Execution: Dosing Errors, A Preventable Harm

Scott Gavura | December 15, 2010

In my last post, I noted how cough and cold products for children have largely been withdrawn from the market due to their lack of efficacy, and the risks related to toxicity. Today's post is going to dive a little more deeply into factors that can contribute to toxicity in the pediatric population. Let's start with a vignette that may be familiar to parents:

The new father is wakened from a blissful, deep sleep by a crying child. Once Dad realizes when and where he is, and the source of the crying, he silently curses the short duration of action of the acetaminophen liquid he gave his child at bedtime. It has probably worn off already, and the fever is back. Stumbling into his child's room in the dark, he can feel the heat radiating off his body. He fumbles around for the Tylenol, and something to measure it with. He can't find the dropper bottle, but finds a bottle of syrup. It's hard to measure the dose in the dark, and the medicine cup he finds is hard to read. 'I think the dose is a teaspoon'that's 5mL'. He pours the medicine into his child's throat, tucks him back into bed, and both are back asleep within minutes.

Did this parent measure the acetaminophen dose correctly? What factors could contribute to a dosing error in this situation?

Dosing errors are among the most common and most preventable causes of adverse drug events in children. Why children? Drugs for children are often in liquid form for ease of measurement and administration. Typically dosed based on milligrams per kilogram, liquid formulations allow us to (in theory) deliver the exact dose that's appropriate. But measurement isn't always easy or intuitive. What's the best way to measure 2.5mL (half a teaspoon)? How easy is it to confuse teaspoons (5mL) and tablespoons (15mL)? And what instructions should health professionals give parents and caregivers to ensure they can measure and administer a dose accurately? Despite the prevalence of dosing errors, there has been little evidence telling us what health professionals, or parents, can do better. Until now

Click here to read the rest of Scott's post.

More Blog Posts by Scott Gavura

Scott Gavura, BScPhm, MBA, RPh, works in the Ontario cancer system and has a professional interest in improving the cost-effective use of drugs at the population level, primarily focusing on evaluating new drugs.  He is a registered pharmacist in Ontario. He blogs on the Science-Based Pharmacy blog which he describes as “Turning an eye on the profession, separating fact from fiction on both sides of the counter”. This post originally appeared on the Science-Based Medicine blog.

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Children and Young People's Health   Scott Gavura   Make Good Treatment Decisions  

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