http://www.ismp.org/NAN/files/NAN-20150630.pdf

ASHP and the Institute for Safe Medication Practices (ISMP) released a National Alert for Serious Medication Errors, recommending the replacement of dosage cups that measure liquid medications in fluid drams with cups that measure only in metric (mL).

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