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Medication errors linked to US use of archaic measuring system

The old measure of the English yard was the distance from the King's nose to the tip of his outstretched hand
The old measure of the English yard was the distance from the King's nose to the tip of his outstretched hand
Robin Wulffson, MD

Medication errors can have a significant impact; too little medication will not adequately treat a medical problem, while too much can produce harmful, and even toxic side effects. When our nation was founded, we adopted the English system of measurement, which any scientist would deem illogical. England, like most of the planet, has adopted the metric system. A new study has found that failure to adopt the milliliter has resulted in medication errors among children. For example, a teaspoon is an arbitrary amount, while 5 milliliters is a precise amount. Another study in the same journal reviewed the impact of medication errors and offered suggestions for improvement. Both studies were published online on July 14 in the journal Pediatrics.

The first study was conducted by researchers at New York University School of Medicine and Pennsylvania State University College of Medicine. The authors noted that adoption of the milliliter as the preferred unit of measurement has been proposed to improve the clarity of medication instructions. For example, they explain that teaspoon and tablespoon units may unintentionally result in nonstandard kitchen spoon use. Therefore, they evaluated the relationship between the unit used and parental medication; they also examined whether nonstandard instruments facilitated this relationship.

The study group comprised 287 English- or Spanish-speaking children whose children were prescribed liquid medications in two emergency departments. A medication error was defined as: error in knowledge of prescribed dose, error in observed dose measurement, compared to intended or prescribed dose. The error threshold was a greater than 20% deviation. The data was subjected to statistical analysis and adjusted for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (via the Short Test of Functional Health Literacy in Adults); child age, and chronic disease.

The researchers were found that medication errors were common; 39.4% of parents made an error in measurement of the intended dose and 41.1% made an error in the prescribed dose. In addition, 16.7% used a nonstandard instrument. Compared with parents who measured medications in milliliters, parents who used teaspoon or tablespoon units had twice the likelihood of making a measurement error in the intended dose (42.5% vs. 27.6%; 2.3-fold increased risk). In regard to prescribed dose, the percentages were 45.1% vs. 31.4% (19-fold increased risk). As expected, parents with low health literacy and non–English speakers made more errors. The authors concluded that their findings support a milliliter-only standard to reduce medication errors.

The second study was conducted by researchers at: Children’s Hospital at Montefiore, Bronx, New York; Medical University of South Carolina, Charleston, South Carolina; Johns Hopkins University School of Medicine, Baltimore, Maryland; and University of California, San Francisco East Bay, Oakland, California. The study authors note that medication errors cause significant morbidity and mortality in children. Therefore, they conducted a study to determine the effectiveness of interventions to reduce pediatric medication errors. They performed a meta-analyses on comparable studies. (A meta-analysis is a compilation of data from a number of studies to clarify a point.)

The researchers identified pertinent studies from PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature. Studies were included it they contained peer-reviewed original data in any language that evaluated an intervention to reduce medication errors in children. A total of 274 full-text articles were reviewed; 63 were included in the study. Only 1% of studies were conducted at community hospitals, 11% were conducted in outpatient clinics, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data. The authors noted that these percentages suggested persistent research gaps.

The investigators found that variation existed in the methods, definitions, outcomes, and rate determinations for all studies; furthermore, many were found to have a significant risk of bias. Twenty-six studies (41%) involved computerized provider order entry; however, a meta-analysis was not performed because of a difference of methods used for data entry. They found that a computerized system reduced errors. A comparison of computerized provider order entry with clinical decision support versus studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; furthermore, studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors.

The authors concluded that pediatric medication errors can be reduced; however, they were unclear regarding what optimal interventions should be. They recommended that future research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Take home message:

Parents have little control over intervention methods by healthcare professionals and medical facilities; however, they can insist on receiving pediatric medication instructions in milliliters. Many liquid pediatric medications come with a dispenser measured in milliliters; if not, one can be purchased at little cost. Also, make sure that the correct dosage is measured. Hold the container at eye level and sight along the measurement bars.

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