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Pediatrics. 2014 Aug;134(2):e354-61. doi: 10.1542/peds.2014-0395. Epub 2014 Jul 14.

Unit of measurement used and parent medication dosing errors.

Author information

  • 1Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
  • 2Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
  • 3Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; and.
  • 4Department of Pediatrics, New York University School of Medicine and Woodhull Medical Center, New York, New York.



Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.


Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.


Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors.


Findings support a milliliter-only standard to reduce medication errors.

Copyright © 2014 by the American Academy of Pediatrics.


ambulatory care; health communication; health literacy; medication errors

[PubMed - indexed for MEDLINE]
[Available on 2015-08-01]
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