New York—Pharmacists, make sure parents have oral syringes instead of cups when dispensing smaller doses of liquid pediatric medications. That’s the advice of a new study pointing out that poorly designed labels and packaging are among the biggest contributors to medication errors.

The report, published recently in the journal Pediatrics, looked at the extent to which dosing error rates are affected by tool characteristics—such as type and marking complexity—and discordance between units of measurement on labels and dosing tools. The study team, led by researchers from the NYU School of Medicine-Bellevue Hospitals, also focused on the effect of differences in health literacy and language.

“Over the past decade, growing attention has been paid to the problem of unintentional medication errors resulting from suboptimal drug labeling and medication packaging,” study authors point out. “Although considerable progress has been attained in making labeling improvements for adult medications, to date there has been limited work incorporating a pediatric perspective, despite studies documenting parent dosing error rates of ≥40%. Lack of evidence regarding best practices has been a barrier to establishing standards related to the labeling and dosing of pediatric medications.”

For the randomized, controlled experiment in three urban pediatric clinics, 2,110 English- or Spanish-speaking parents of children 8 years old or younger were randomly assigned to one of five study arms and given labels and dosing tools that varied in unit pairings.

Each parent measured nine doses of medication consisting of three amounts—2.5, 5, and 7.5 mL—and using three tools (one cup, a 0.2-mL-increment syringe or a 0.5-mL-increment syringe) in random order.

The study team then assessed the outcomes, defined as dosing error of greater than 20% deviation or large error defined as more than two times the dosage.

Results indicate that 84.4% of parents made one or more dosing errors, 21% of those being large errors. Especially for smaller doses, more errors were seen with cups than syringes, with an adjusted odds ratio of 4.6, across health literacy and language groups.

On the other hand, no differences in error rates were detected between the two syringe types. Use of a teaspoon-only label—with a milliliter and teaspoon tool—appeared to result in more errors than when milliliter-only labels and tools were used, for an adjusted OR of 1.2.

“Unlike most prescription drugs taken by adults, pediatric medications are unique in their reliance on liquid formulations,” researchers explain. “With oral liquid medicines, parents must choose an appropriate tool with which to measure and administer medicine to their children. In addition, a range of measurement units (eg, milliliter, teaspoon, tablespoon), along with their associated abbreviations, are used as part of instructions on labels and dosing tools, contributing to confusion and multifold errors.”

To promote dosing accuracy, both the American Academy of Pediatrics and the FDA recommend that parents use dosing tools with standard markings—e.g., oral syringes, droppers, dosing cups—rather than nonstandard kitchen spoons, which vary widely in size and shape. No national guidelines exist, however, as to the type of tool which should be provided to families, according to the study authors, who call oral syringes the “gold standard” when accuracy is critical.

They also point out that cups are most frequently included with OTC products, even though they have a higher rate of parent error.

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