The national alert follows an account of a fatal event recently reported to the ISMP National Medication Errors Reporting Program (MERP), in which a nurse confused two dosing scales (drams and mL) appearing on a plastic oral liquid dosing cup and mistakenly administered an overdose of morphine sulfate.
To prevent these types of mix-ups between variable measurement systems, multiple organizations have called for the adoption of mL as the standard for prescribing and measuring liquid medication doses. Although hospitals have made progress in prescribing liquids in mL, many continue to use dosing devices that have household measures (such as teaspoons and tablespoons), drams, and ounces.
Oral syringes that measure only in mL should be used for measuring liquid medication doses wherever possible. When cups must be used, ideally they should allow measurement in mL only. Although these cups are not widely available at this time, some suppliers can customize dosing cups to measure in mL only. If a customized cup is unavailable, hospitals may need to rely on cups measuring in mL and household measures until mL-only cups can be supplied.
When a significant risk for serious or fatal errors is detected through ISMP’s reporting program, ASHP and ISMP issue National Alert Network (NAN) alerts. Alerts are distributed to healthcare practitioners and organizations through ISMP, ASHP, and the National Council on Medication Error Reporting and Prevention.
For a copy of the alert, which provides additional recommendations for safe oral liquid medication dosing, go to http://www.ismp.org/NAN/files/NAN-20150630.pdf.
About ASHPASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s more than 40,000 members include pharmacists, student pharmacists, and pharmacy technicians. For over 70 years, ASHP has been on the forefront of efforts to improve medication use and enhance patient safety. For more information about the wide array of ASHP activities and the many ways in which pharmacists advance healthcare, visit ASHP’s website, www.ashp.org, or its consumer website, www.SafeMedication.com.
About ISMPThe Institute for Safe Medication Practices (ISMP) is an independent, nonprofit charitable organization that works closely with healthcare practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. ISMP represents nearly 40 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. ISMP is a federally certified patient safety organization (PSO), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute. For more information on ISMP, or its medication safety alert newsletters and other tools for healthcare professionals and consumers, visit www.ismp.org or its consumer website, www.consumermedsafety.org.
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