Effect of Medication Label Units of Measure on Parent Choice of Dosing Tool: A Randomized Experiment

Syntax Error: Variations in the Verbiage of Prescription Labels for Pediatric Liquid Medications

Background Pharmacists can modify prescriptions from prescribers for clarity and patient understanding, provided the confines of the original order are met, yet the verbiage used by pharmacists is not standardized. Prescription directions for children, especially children eight years old and younger, should be written with the verb "give" instead of "take" as their parents or caregivers are expected to administer them. Errors in prescribing, dispensing, and administering medication comprise a significant portion of preventable medical errors in children. To intervene and assist pharmacies, we must first identify and characterize the problem. This study aimed to determine if there is a relationship between prescribers and pharmacists using the verb "give" or "take" when prescribing and printing prescription labels for pediatric liquid medications. In addition, it aimed to determine if there is a relationship between chain pharmacies and independent pharmacies using the verb "give" or "take" when printing labels for pediatric liquid medications. Methodology The participants in this study were caregivers of children eight years old and younger who had been prescribed a new liquid medication. We recruited prescribers in North Louisiana to serve as a referral base for the study. Caregivers were referred to the study by prescribers. A rubric was created to investigate the text of prescription labels. Fisher's exact test was used to determine the relationship between verb choice and prescribers and pharmacists, as well as the relationship between verb choice and chain pharmacies and independent pharmacies. Results A total of 11 (26.83%) prescriber texts used the verb "give," while 12 (29.27%) prescriber texts used the verb "take." Overall, 18 (43.90%) prescriber texts did not use a verb at all. Of these 18 prescriber texts that did not include a verb, 14 prescription labels used the verb "give," and four used the verb "take." In total, 10 (23.81%) chain pharmacy prescription labels used the verb "give," and 10 (23.81%) chain pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between prescribers and pharmacists equaled 0.0001. A total of 19 (46.34%) independent pharmacy prescription labels used the verb "give," and two (4.88%) independent pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between chain pharmacies and independent pharmacies equaled 0.0063. Conclusions The relationship between prescriber texts and pharmacist prescription labels shows a relationship between their verb choice (p = 0.0001). The relationship between chain pharmacy and independent pharmacy prescription labels shows a relationship between their verb choice (p = 0.0063). This study has illuminated how medication orders begin before they are modified, if necessary, for the patient's clarity and understanding. This study can be used to instruct prescribers on writing more accurate prescription instructions to prevent medical errors, and it can help pharmacists recognize potential dangers and prevent them through editing.

Mothers' ability to determine and measure paracetamol doses for children-a contrived observational study

Caregivers are primarily responsible for the administration of Over The Counter (OTC) medications in children. This study examines the mothers' ability to determine and measure paracetamol doses for children aged between 1 and 5 years. A contrived observational study was conducted for mothers of preschool aged children at two Public Health Midwifery (PHM) areas in Southern province, Sri Lanka. Stratified random sampling was used. Only 26.9% (n = 95, 95% CI = 22.5%-31.7%) of the 353 participants correctly determined and measured the doses of paracetamol. Errors were frequently made in both determining and measuring dose together (n = 113, 32.0%, 95% CI = 27.3%-37.1%), determining only (n = 94, 26.6%, 95% CI = 22.2%-31.5%) and measurement only (n = 51, 14.4%, 95% CI = 11.1%-18.5%). Dose determined errors were not significantly associated with maternal education, number of children in the family, total monthly income and age of the index child. Similarly measuring errors were not significantly associated with mothers' education, income of the family and number of children in the family. However, there was a weak positive correlation between measuring errors and age of the index child. The study suggests that mothers made errors when determining doses and measuring doses of paracetamol. Results emphasize importance of clear, concise guardian information leaflet and healthcare professionals' guidance to minimize dosing errors of child medication.

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital

OBJECTIVE

To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital.

METHODS

This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service.

RESULTS

A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761).

CONCLUSIONS

Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

Improving Caregiver Understanding of Liquid Acetaminophen Administration at Primary Care Visits

OBJECTIVES

Liquid medication dosing errors are common in pediatrics. Our outpatient clinic identified gaps in caregiver education based on a 2015 American Academy of Pediatrics policy statement on prescribing liquid medications. This quality improvement (QI) initiative sought to improve caregiver's understanding of liquid acetaminophen administration at the 2-month well-child visit from 30% to 70% over a 32-month period.

METHODS

A resident-led interdisciplinary QI team performed sequential interventions to improve our outcome measure: the percentage of caregivers with an adequate understanding of 4 essential components of liquid acetaminophen administration (name, indication, dose, and frequency). Outcome data were collected via a 4-item verbal assessment of caregiver's understanding by nursing staff, with correct answers to all items considered adequate understanding. Process measures (medications prescribed and education provided), and balancing measures (anticipatory guidance items discussed) were gathered via electronic health record review. Shewhart "P" charts and established rules for detecting special cause variation were used to analyze data. Scatter plots assessed the association between the provision of syringes and caregiver understanding of medication administration.

RESULTS

In 636 caregivers, overall understanding of medication use improved from 39.8% to 74%. Knowledge of accurate dosage improved from 50.9% to 76.8%. Correlation between syringe provision and caregiver understanding was strong (R = .84).

CONCLUSIONS

Resident-led QI improved caregiver's understanding of liquid acetaminophen administration in infants. The most impactful interventions were implementation of English and Spanish pictograms and provision of dose-demarcated oral syringes, coupled with teach-back. Future interventions will examine generalizability to other medications and expansion to other services.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Pathways linking parental health literacy with health behaviours directed at the child: a scoping review

Health literacy (HL) is thought to be crucial for the management of the manifold demands relating to child health which parents are faced with. Albeit many studies have investigated parental HL and health behaviours (HBs) directed at the child, knowledge about the pathways which link parental HL with HB is scarce. The aim of this scoping review was to identify and comprehensively describe the variety of pathways linking parental HL with HBs directed at the child which were empirically analysed in previous studies. Following established scoping review methods database searches were conducted in MEDLINE, EMBASE, PsycINFO and WebofScience on 5 March 2020. Eligibility criteria included primary, empirical studies assessing parental HL and HB directed at the child in the general parent population. Titles and abstracts were screened independently by six reviewers for potentially relevant publications and data were extracted using standardized data extraction forms. The search identified 6916 articles for title and abstract screening. After full-text review, 50 studies were included in this review. Most studies (N = 24) assumed a direct association between HL and HBs and only few studies (N = 4) used more complex models investigating different pathways or mediation and/or moderation models. Overall, the evidence on the underlying pathways linking parental HL and HBs directed at the child is mixed and fairly limited. Therefore, hypothesis-driven research and integration of results into theoretical frameworks is needed for advancing both the research on HL and public health practice.

Can use of pictograms reduce liquid medication administration errors by mothers? An interventional study

Background

Liquid medication dosing errors (LMDE) made by caregivers affect treatment in children, but this is not a well-studied topic in many low-and middle-income countries including in India.

Methods

An intervention study was conducted among mothers attending a pediatric outpatient clinic of a tertiary care setting in Ujjain, India. The mothers randomly measured 12 volumes of a paracetamol liquid preparation by using a dropper (0.5 and 1 mL), measuring cup (2.5 and 5 mL), and calibrated spoon (2.5 and 5 mL) each with two instructions—oral-only measurement session (OMS) and oral plus pictogram measurement session (OPMS, the intervention). The main outcome was dosing error prevalence. The effectiveness of the intervention was assessed by measuring effect size. Risk factors for maximum LMDE were explored using backward multivariate logistic regression models. A P value of < 0.05 was considered statistically significant.

Results

In total, 310 mothers [mean (± SD) age, 30.2 (± 4.18) years] were included. LMDE prevalence in the OMS versus OPMS for dropper 0.5 mL was 60% versus 48%; for l mL dropper was 63% versus 54%; for 2.5 mL cup 62% versus 54%; for 2.5 calibrated spoon 66% versus 59%; 5 mL cup 69% versus 57%; and 5 mL calibrated spoon 68% versus 55%. Comparing OMS with OPMS, underdosing was minimum with the calibrated spoon for 2.5 mL (OR 4.39) and maximum with the dropper for 1 mL (OR 9.40), and overdosing was minimum with the dropper for 0.5 mL (OR 7.12) and maximum with the calibrated spoon for 2.5 mL (OR 13.24). The effect size (d_Cohen) of the intervention OPMS was 1.86–6.4. Risk factors for the most prevalent dosing error, that is, with the calibrated spoon for 2.5 mL, were increasing age of the mother (aOR 1.08; P = 0.026) and nuclear family (aOR 2.83; P = 0.002). The risk of dosing errors decreased with higher education of the mothers.

Conclusions

Pictograms can effectively minimize LMDE even in less educated mothers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00584-9.

NCPDP recommendations for standardizing dosing in metric units (mL) on prescription container labels of oral liquid medications, version 2.0

PURPOSE

Best practices and guidance are provided for standardizing dosing instructions on prescription container labels of oral liquid medications by eliminating use of U.S. customary (household) units and adopting metric units universally, with the goal of decreasing the potential for error and improving safety and outcomes when patients and caregivers take and administer these medications.

SUMMARY

Despite decades of best practice use of metric units in organized healthcare settings and advocacy by various professional societies, medication safety experts, and standards setting organizations, use of household units (e.g., teaspoon) on prescription container labeling instructions for oral liquid medications persists in community pharmacy settings. Five years after publication of the National Council for Prescription Drug Programs' (NCPDP's) original white paper advocating metric-only dosing, very few community pharmacy companies appear to require oral liquid dosing instructions be presented in metric-only units (mL). Error-prone dosing designations contribute to medication errors and patient harm. Use of both multiple volumetric units (e.g., teaspoonsful, tablespoonsful) and multiple abbreviations for the same volumetric units (e.g., mL, cc, mls; tsp, TSP, t) increases the likelihood of dosing errors. Opportunities for error exist with each administration of an oral liquid medication and, unless coordinated with dispensing of appropriate oral dosing devices and optimal counseling, can result in use of household utensils (e.g., uncalibrated teaspoons) or discordantly marked devices that can further exacerbate the risk of error. Since publication of NCPDP's original white paper, new standards have been adopted governing official liquid volume representation, calibrated dosing devices, and e-prescribing software which support the elimination of non-metric units to reduce use of dosing practices that are error-prone. In each case, U.S. customary (household) units have been eliminated in official standards and certification requirements. Therefore, use of non-metric units for oral dosing of liquid medications no longer is an acceptable practice.

CONCLUSION

Key factors contributing to dosing errors with oral liquid medications include use of multiple volumetric units and abbreviations; failure to institute policies and procedures that eliminate the use of non-metric (e.g., household) units and universally adopt metric-only dosing instructions in all settings; failure to coordinate dosing instructions with dosing device markings, appropriate type (oral syringe versus cup), and optimal volumes (e.g., 1-, 5-, or 10-mL devices); failure to adequately counsel patients about appropriate measurement and administration of oral liquid medication doses; and use or error-prone practices such as missing leading zeros and elimination of trailing zeros in prescriptions and container labels. Adoption of this white paper's recommendations will align dosing designations for oral liquid medications in all settings with current standards and attain universal metric-only practice.

Parent Dosing Tool Use, Beliefs, and Access: A Health Literacy Perspective

OBJECTIVES

To assess parent decision-making regarding dosing tools, a known contributor to medication dosing errors, by evaluating parent dosing tool use, beliefs, and access, and the role of health literacy, with a focus on dosing cups, which are associated with an increased risk of multifold overdose.

STUDY DESIGN

Cross-sectional analysis of data collected for randomized controlled study in 3 urban pediatric clinics. English/Spanish-speaking parents (n = 493) of children ≤8 years of age enrolled.

OUTCOMES

reported tool use, beliefs, and access. Predictor variable: health literacy (Newest Vital Sign; limited [0-3], adequate [4-6]). Multiple logistic regression analyses conducted.

RESULTS

Over two-thirds of parents had limited health literacy. Oral syringes (62%) and dosing cups (22%) were most commonly used. Overall, 24% believed dosing cups were the best tool type for dosing accuracy; 99% reported having access to ≥1 dosing tools with standard measurement markings. Parents with limited health literacy had greater odds of dosing cup use (limited vs adequate: aOR = 2.4 [1.2-4.6]). Parents who believed that dosing cups are best for accuracy had greater odds of dosing cup use (aOR = 16.3 [9.0-29.3]); this belief mediated health literacy-effects on dosing cup use.

CONCLUSIONS

Factors associated with dosing tool choice, including parent health literacy and beliefs are important to consider in the design of interventions to reduce dosing errors; future larger-scale studies addressing this issue are needed.

Identification of Errors in Pediatric Prescriptions and Interventions to Prevent Errors: A Survey of Community Pharmacists

OBJECTIVES

Assess the competency of community pharmacists in identifying errors in pediatric prescriptions and to determine how often pharmacists perform interventions known to mitigate the likelihood of error. The study sought to recognize factors that may impact the pharmacist's ability to identify and mediate these errors, and to detect barriers that limit the role of the pharmacist pediatric patient care.

METHODS

A survey was distributed through the University of Illinois at Chicago College of Pharmacy Alumni Network and the Illinois Pharmacists Association email listservs. Pharmacists practicing in a retail setting within the last 5 years were included. Three prescription scenarios for commonly used pediatric medications with corresponding questions were created to assess a pharmacist's ability to identify errors. Demographics pertaining to the pharmacist and the practice site, as well as information about dispensing practices, were collected. Logistic regression was used to identify factors that might impact the pharmacists' ability to identify errors.

RESULTS

One hundred sixty-one respondents began the survey and 138 met inclusion criteria. In 15% to 59% of scenario-based questions, pharmacists did not appropriately identify errors or interventions that would decrease the likelihood of error. Correct identification of doses was associated with total prescription volume in one scenario and with pediatric prescription volume in another scenario. Pharmacists did not consistently label prescriptions for oral liquids in milliliters or dispense oral syringes. Barriers to pharmacist involvement included availability and interest of the caregiver, ability to contact prescriber, and pharmacy staffing.

CONCLUSION

Community pharmacists did not consistently identify medication errors or use interventions known to mitigate error risk.

Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging Improvements

OBJECTIVE

To assess the impact of the 2011 changes in pediatric single-ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison control center exposures due to medication errors.

METHODS

National Poison Data System (NPDS) data from January 1, 2007, through December 31, 2016, were used to identify medication error exposures involving single-ingredient liquid acetaminophen in children younger than 12 years of age. Surveys were conducted through 6 regional poison control centers to obtain additional information on a subset of exposures.

RESULTS

The annual frequency of NPDS exposures due to medication errors with single-ingredient liquid acetaminophen products was 8260 ± 670 exposures/year during 2007-2011. Children <2 years of age accounted for 66% of exposures. The overall rate of exposures fell to 6669 ± 662 during 2012-2016 (19% decrease; P = .005). Four percent of exposures led to health care facility referrals. Caregivers involved with exposures in children <2 years of age cited health professionals as the source of dosing information in only 69% of cases despite the absence of specific dosing directions for these children on product labels.

CONCLUSIONS

Implementation of a single concentration for pediatric liquid acetaminophen products and packaging changes were associated with a decrease in medication errors reported to poison control centers. Medication errors are particularly problematic for children <2 years of age, for whom there are no specific labeled dosing instructions. Improved efforts to provide caregivers with dosing instructions for these children are encouraged.

Primary Care Provider Perceptions and Practices Regarding Dosing Units for Oral Liquid Medications

INTRODUCTION

To prevent errors, health care professional and safety organizations recommend using milliliters (mL) alone for oral liquid medication dosing instructions and devices. In 2018, for federal incentives under the Quality Payment Program, one requirement is for electronic health records to automatically use mL alone whenever oral liquid medications are prescribed. Current perceptions and practices of primary care providers (PCPs) regarding dosing units for oral liquid medications were assessed.

METHODS

Pediatricians, family practitioners, nurse practitioners, and internists participating in the 2015 DocStyles Web-based survey were asked about their perceptions and practices regarding dosing units for oral liquid medications.

RESULTS

Three fifths of PCPs (59.0%) reported that using mL alone is safest for dosing oral liquid medications; however, nearly three quarters (72.0%) thought that patients/caregivers prefer instructions that include spoon-based units. Within each specialty, fewer PCPs reported they would prescribe using mL alone than reported that using mL alone is safest (P < .0001 for all). Among PCPs who think milliliter-only dosing is safest, those who perceived patients/caregivers prefer including spoon-based units were less likely to prescribe using mL alone (odds ratio 0.45, 95% confidence interval 0.34-0.59). Pediatricians were more likely than other PCPs to report that it is safest to use mL alone (80.8% vs 54.7%) and that they would use mL alone when prescribing (56.8% vs 30.9%) (P < .0001 for both).

CONCLUSIONS

Because less than two thirds of pediatricians and one third of other PCPs would use mL alone in dosing instructions, additional education to encourage prescribing and communicating with patients/caregivers using mL alone may be needed.

Parents' pain medication underdosing is associated with more emergency department visits in sickle cell disease

OBJECTIVE

To determine the association between health literacy, medication knowledge, and pain treatment skills with emergency department (ED) use of parents of children with sickle cell disease (SCD).

METHODS

Parents of children 1- to 12-years-old with SCD were enrolled. Health literacy was assessed using the Newest Vital Sign. Parents completed a structured interview assessing knowledge of the dosage and frequency of home pain medications and an applied skills task requiring them to dose a prescribed pain medication. Underdosage was defined by too small a dose (dosage error) or too infrequent a dose (frequency error). The association between medication knowledge and applied skills with ED visits for pain over the past year was evaluated using Poisson regression adjusting for genotype.

RESULTS

One hundred parent/child pairs were included; 50% of parents had low health literacy. Low health literacy was associated with more underdose frequency errors (38% vs. 19%, P = 0.02) on the skills task. On medication knowledge, underdose dosage errors (adjusted incidence rate ratio [aIRR] 2.0, 95% confidence interval [CI] 1.3-3.0) and underdose frequency errors (aIRR, 1.7, 95% CI 1.2-2.6) were associated with a higher rate of ED visits for pain. On the skills task, underdose dosage errors (aIRR 1.6, 95% CI 1.1-2-.4) and underdose frequency errors were associated with more ED visits (aIRR 1.5, 95% CI 1.1-2.1).

CONCLUSIONS

For medication knowledge and skills tasks, children of parents who underdosed pain medication had a higher rate of ED visits for pain. Health literate strategies to improve parents' medication skills may improve pain treatment at home and decrease healthcare utilization.

Parent Preferences and Perceptions of Milliliters and Teaspoons: Role of Health Literacy and Experience

BACKGROUND AND OBJECTIVES

A recent American Academy of Pediatrics policy statement recommends milliliter-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to milliliters only, and the role of health literacy and prior milliliter-dosing experience.

METHODS

Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE Rx for Kids study). English- and Spanish-speaking parents (n = 493) of children aged ≤8 years were randomized to 1 of 4 study arms and given labels and dosing tools which varied in label instruction format (text plus pictogram, text only) and units (milliliter only ["mL"], milliliter/teaspoon ["mL"/"tsp"]). Outcomes included teaspoon preference in dosing instructions and perceived difficulty with milliliter-only dosing. The predictor variable was health literacy (Newest Vital Sign; low [0-1], marginal [2-3], adequate [4-6]). The mediating variable was prior milliliter-dosing experience.

RESULTS

Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use milliliters, perceived milliliter-only dosing to be easy, and had prior milliliter-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived milliliter-only dosing will be difficult, and 17.7% had no prior milliliter-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs adequate: adjusted odds ratio [AOR] = 2.9 [95% confidence interval [CI] 1.3-6.2]), and greater odds of perceiving difficulty with milliliter-only dosing (low vs adequate: AOR = 13.9 [95% CI 4.8-40.6], marginal vs adequate: AOR = 7.1 [95% CI 2.5-20.4]). Lack of experience with milliliter dosing partially mediated the impact of health literacy.

CONCLUSIONS

Most parents were comfortable with milliliter-only dosing. Parents with low health literacy were more likely to perceive milliliter-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study

BACKGROUND AND OBJECTIVES

Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes.

METHODS

This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children ≤8 years old were randomly assigned to 1 of 4 groups and given labels and dosing tools that varied in label instruction format (text and pictogram, or text only) and units (milliliter-only ["mL"] or milliliter/teaspoon ["mL/tsp"]). Each parent measured 9 doses of liquid medication (3 amounts [2, 7.5, and 10 mL] and 3 tools [1 cup, 2 syringes (5- and 10-mL capacities)]) in random order. The primary outcome was dosing error (>20% deviation), and large error (>2× dose).

RESULTS

We found that 83.5% of parents made ≥1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made ≥1 large error (>2× dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2-0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7-10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0-5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5-2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05-1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1-3.3], aOR = 2.5 [1.4-4.6], respectively).

CONCLUSIONS

Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.