Medication Errors among Children: Are Parents to Blame?

As parents, many of us have had the task of administering doses of both common over-the-counter and prescription liquid products to our children for treatment of fever, cough, and infections including otitis media. As pharmacists, we are experts in understanding dosing regimens including the use of proper dose delivery devices (e.g. droppers, oral syringes, dosing cups, and spoons). However, parents have difficulty with this concept, which results in medication errors including overdoses on a daily basis in this country. Recently a new study in Pediatrics assessed medication measuring errors in 287 parents. Approximately 39% of parents made an error in measurement of the intended dose, 41% made an error in the prescribed dose, and more than 16% used a nonstandard measuring instrument such as a kitchen spoon rather than a measuring device provided with the medication.¹     

As a pharmacist and a parent, I have had the misfortune of experiencing problems with dosing instruments. As my two young girls were experiencing multiple otitis media infections, I obtained prescriptions from my local retail chain pharmacy. Of the 8 times I picked up my antibiotic suspension from two pharmacies (both the same retail chain), they failed to provide me with the proper dosing instrument on EVERY occasion. Of course, I approached the pharmacist to obtain the proper dosing device, and EVERY time I vented my frustration to the safety lapses of this practice. It alarms me that the average parent may not receive proper counseling or the right dosing instrument to deliver the prescribed medication dose. Based upon this practice, the evidence has shown that there are upwards of over 10,000 calls to national poison control centers annually due to this problem. The problem occurs due to a lack of standard measurement on liquid medications.

Ordinary kitchen teaspoons differ in size, shape, and depth, leading to vast differences in dosing volume compared to using a medicinal dosing spoon, oral syringe, or dosing cup with markings. This results in parents accidently overdosing or under dosing their child substantially.  Since medications are just another commodity, it is difficult sometimes to educate parents of the importance of this issue. I would be interested in any pharmacists actively involved with medication safety initiatives for young parents. Do any pharmacists provide community education or other services promoting child dosing safety? Is it your standard practice to provide standard medicinal dosing devices and education in the use of each device for all parents/caregivers of young children after dispensing a prescription? I welcome any thoughts on this issue.

Michael J. Cawley, PharmD, RRT, CPFT, FCCM, is a Professor of Clinical Pharmacy at the Philadelphia College of Pharmacy, University of the Sciences. He has greater than 25 years of experience practicing in the areas of medical, surgical, trauma, and burn intensive care as both a critical care clinical pharmacist and registered respiratory therapist.

Reference:

1. Yin HS, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2):e354-361.