The American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP) recently released a national alert calling for uniform scales when measuring liquid medications. This alert followed a fatal incident when a nurse mistakenly administered an overdose of morphine to a patient after confusing the dosing scales.
The Proposed Mandate
To prevent dosing mix-ups, both ASHP and ISMP recommend the adoption of the metric system (mL) to measure liquid medications. Many hospitals have already mandated this change, but some still use household measurements, such as tablespoons, drams, or ounces. Oral syringes that measure only in mL are commonly available, but in the instance that a cup must be used, the recommendation is to use customizable cups to set the dosing unit.
According to the ECRI Institute, inconsistent measurement scales are one of the top ten patient safety concerns for healthcare institutions today. Though they focus on the measure of pounds versus kilograms when it comes to entering the weight of patients, particularly when calculating medication doses, they too recommend the use of standardized measures for liquid medications. Read more about the ECRI’s patient safety concerns on our blog.
These regulations come at a crucial time given the rapid increase of temporary or traveling nurses–the main distributors of medication in the hospital. When nurses frequently move between facilities, the use of different units of measure increases the risk of a medication error. Through standardization of measures across the industry, these nurses will be able to acclimate to new facilities faster and help prevent these types of errors. Additionally, as telemedicine and labor sharing programs grow in popularity, hospitals will benefit from adopting policies that conform to industry standards, rather than continually having to retrain providers on the hospital’s specific measuring scale.
What other benefits do you see for standardizing dosing scales across the industry? Are there any drawbacks to adopting this new system?