Consider the following real-life scenarios:
These real and serious cases—one resulted in a child’s death—illustrate a small sample of liquid dosing errors that have been reported to the Institute for Safe Medication Practices (ISMP). The ISMP has received at least 50 reports of just 1 type of error, confusing milliliters with teaspoons. The reports provide a window into how easily nonstandardized dosing can compromise medication safety and have spurred a public-private effort to standardize liquid medication dosing for products obtained at community pharmacies.
Kuehn BM. Group Urges Going Metric to Head Off Dosing Mistakes. JAMA. 2014;311(21):2159–2160. doi:10.1001/jama.2014.5090
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