Preventing Medical Errors Preventing Medical Errors
U.S. Food and Drug Administration

Parent Errors in Measuring Children’s Doses

The Institute for Safe Medication Practices (ISMP) recently reported on a study of the errors parents make when measuring children’s doses of oral medications. In the study, 300 parents were observed as they attempted to measure liquid doses using dosing cups, droppers, dosing spoons and oral syringes.

Parents using dosing cups made many more errors than those using the other methods. The cups were also associated with large dosing errors, where the measured dose differed from the prescribed dose by more than 40 percent. Parents with low health literacy scores were more likely to make errors.

The authors of the study speculate that the higher failure rate with the dosing cups might be due to legibility difficulties, or to parents assuming that a full cup is the unit of measure, or to confusion between teaspoon “tsp” and tablespoon “tbsp” markings, especially with the abbreviations for teaspoon and tablespoon.

When using the dosing cups, parents should always verify the dose at eye level. But whichever dosing device you provide for your patients, ISMP recommends using the "teachback method." That is where the parent or caregiver demonstrates they understand how to use the device before it’s dispensed.