Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment.
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.
Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York; yinh02@med.nyu.edu.|Department of Population Health, NYU School of Medicine, New York, New York.
H Shonna
HS
Yin
Department of Medicine.
Ruth M
RM
Parker
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
Lee M
LM
Sanders
Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York.
Benard P
BP
Dreyer
Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York.
Alan L
AL
Mendelsohn
Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina.
Stacy
S
Bailey
Division of General Internal Medicine and Geriatrics, and.
Deesha A
DA
Patel
Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York.
Jessica J
JJ
Jimenez
Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Kwang-Youn A
KA
Kim
Rollins School of Public Health, and.
Kara
K
Jacobson
Division of General Internal Medicine and Geriatrics, and.
Laurie
L
Hedlund
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
Michelle C J
MC
Smith
Department of Pediatrics, NYU School of Medicine-Bellevue Hospital, New York, New York.
Leslie
L
Maness Harris
Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
Terri
T
McFadden
Division of General Internal Medicine and Geriatrics, and.
Michael S
MS
Wolf
D000328:Adult; D002648:Child; D002675:Child, Preschool; D004339:Drug Compounding / Q000379:methods* / Q000706:statistics & numerical data; D054796:Drug Dosage Calculations; D004348:Drug Labeling / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D057220:Health Literacy; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D010290:Parents