Clinicians: Use “mL”-only when Prescribing to Reduce Parent Dosing Errors and Keep Children Safe

Posted on by CDC's Safe Healthcare Blog
H. Shonna Yin, MD, MS
H. Shonna Yin, MD, MS

Guest Author: Shonna Yin, MD, MS

Associate Professor of Pediatrics and Population Health, NYU School of Medicine

One thing that every clinician can do for National Safety Month is make sure they prescribe medications for children in the safest way. Dosing errors are the most common type of medication error that brings children into the Emergency Department. So what can clinicians do?

An easy thing clinicians can do is to choose only milliliter (“mL”) units when they prescribe liquid medications, and use mL-only when they talk to families about medication instructions, as recommended by the American Academy of Pediatrics (AAP). A new study found that while three-fifths of primary care providers report that using mL-alone is safest for oral liquid medications, fewer than two-thirds of pediatricians and one-third of other health care providers would use mL-alone in dosing instructions. Instead, these clinicians chose to provide instructions using teaspoon (tsp) alone, or a combination of mL and tsp. Providers who thought mL-alone was safest, but would include teaspoon units, perceived that parents preferred instructions that included spoon-based units.

Unfortunately, parent confusion with units of measurement contributes to multi-fold dosing errors. For example, confusion between mL and tsp can lead to a 5-fold overdose. Recent research by my team, as part of the National Institutes of Health (NIH)-funded SAFE Rx for Kids study, showed that when mL-only was used, the number of errors leading to large overdoses (of 2-fold or greater) was reduced by 50%, compared to when mL and tsp were used together.

To help ensure that children receive the correct amount of medicine, the American Academy of Pediatrics urges parents, healthcare providers, and pharmacists to use only metric measurements (mL-only) on prescriptions and medication labels, and when possible, to choose dosing tools (like oral syringes) that only have doses listed in milliliters. Medications should not be measured in teaspoons or tablespoons, especially not spoons taken from a kitchen drawer.

Clinicians should review mL-based doses with families when they are prescribed. See more information from the American Academy of Pediatrics here:’s-Medications-Not-Kitchen-Spoons.aspx.

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H. Shonna Yin, MD, MS, is a general pediatrician and an Associate Professor of Pediatrics and Population Health at the NYU School of Medicine. She is an NIH-funded researcher focused on examining strategies to reduce outpatient pediatric medication errors using a health literacy-informed approach. She has been an active member of the CDC’s Prevention of Overdoses and Treatment Errors in Children Taskforce (PROTECT) for the past decade, working with this multisector group to advance children’s medication safety.

Posted on by CDC's Safe Healthcare Blog
Page last reviewed: September 23, 2020
Page last updated: September 23, 2020