Litovitz T
National Capital Poison Center, Washington, DC.
Ann Pharmacother. 1992 Jul-Aug;26(7-8):917-8. doi: 10.1177/106002809202600710.
To characterize reports to poison centers involving liquid medication errors associated with the use of dispensing cups.
Case series reported by 16 US poison centers over an eight-day period.
Calls to poison control centers, predominantly but not exclusively from homes.
Children and adults.
Of 34 reported cases, most (79 percent) involved a two- to threefold dosing error, and most (94 percent) involved an error in a single dose of medication. Cough and cold preparations were implicated in 65 percent; acetaminophen elixirs in 18 percent. Three major causes of dosing errors were identified, including teaspoon/tablespoon confusion, assumption that the dispensing cup was the unit of measure, and assumption that the full dispensing cup was the actual dose.
Dispensing cup markings should use a single unit of measure, and a uniform labeling system should be implemented. Teaspoon/tablespoon abbreviations should be avoided, and dispensing cup lettering should be more legible. Consumer education is essential to correct the misimpression that the full cup is always the recommended dose.
描述向中毒控制中心报告的、与使用配药杯相关的液体药物用药错误情况。
16家美国中毒控制中心在八天时间内报告的病例系列。
主要但不限于来自家庭的致电中毒控制中心。
儿童和成人。
在报告的34例病例中，大多数（79%）涉及两到三倍的剂量错误，且大多数（94%）涉及单剂量药物的错误。止咳和感冒药占65%；对乙酰氨基酚酏剂占18%。确定了剂量错误的三个主要原因，包括茶匙/汤匙混淆、认为配药杯是计量单位以及认为装满的配药杯就是实际剂量。
配药杯标记应使用单一计量单位，并应实施统一的标签系统。应避免使用茶匙/汤匙的缩写，配药杯上的字母应更清晰可读。对消费者进行教育对于纠正认为整杯总是推荐剂量的错误观念至关重要。
