Am J Health Syst Pharm. 2021 Mar 18;78(7):578-605. doi: 10.1093/ajhp/zxab023.
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.
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.
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.
通过消除美国惯用单位（家用单位）并普遍采用公制单位，为规范口服液体药物处方容器标签上的剂量说明提供最佳实践和指导，以减少患者和护理人员在服用和管理这些药物时出错的可能性，并提高安全性和治疗效果。
尽管数十年来在有组织的医疗保健环境中最佳实践使用公制单位以及各种专业协会、药物安全专家和标准制定组织的倡导，在社区药房环境中，口服液体药物的处方容器标签说明上仍继续使用家用单位（例如茶匙）。在国家处方药物计划委员会（NCPDP）最初的白皮书倡导仅使用公制剂量五年后，很少有社区药房公司似乎要求口服液体剂量说明仅以公制单位（毫升）呈现。易出错的剂量指定会导致药物错误和患者伤害。使用多种容量单位（例如茶匙、汤匙）和同一种容量单位的多种缩写（例如毫升、立方厘米、毫升；茶匙、TSP、t）会增加剂量错误的可能性。每次使用口服液体药物都存在出错的机会，除非与适当的口服给药装置和最佳咨询相协调，否则可能会导致使用家用器具（例如未经校准的茶匙）或标记不一致的装置，这可能会进一步加剧错误风险。自 NCPDP 最初的白皮书发布以来，新的标准已被采用，用于规范官方液体体积表示、校准剂量装置和电子处方软件，以支持消除非公制单位，减少使用易出错的剂量方法。在每种情况下，美国惯用（家用）单位已从官方标准和认证要求中删除。因此，不再允许将非公制单位用于口服液体药物的剂量。
导致口服液体药物剂量错误的关键因素包括使用多种容量单位和缩写；未能制定政策和程序，以消除在所有情况下使用非公制（例如家用）单位和普遍采用仅公制剂量说明；未能将剂量说明与剂量装置标记、适当类型（口服注射器与杯子）以及最佳容量（例如 1、5 或 10 毫升装置）相协调；未能充分告知患者关于适当测量和管理口服液体药物剂量的知识；以及使用或易出错的做法，例如在处方和容器标签中遗漏前导零和删除尾随零。采用本白皮书的建议将使所有情况下的口服液体药物的剂量指定与当前标准保持一致，并实现普遍的仅公制实践。
