Implication of Dispensing Cups in Dosing Errors and Pediatric Poisonings: A Report from the American Association of Poison Control Centers

Abstract

OBJECTIVE:

To characterize reports to poison centers involving liquid medication errors associated with the use of dispensing cups. design: Case series reported by 16 US poison centers over an eight-day period.

SETTING:

Calls to poison control centers, predominantly but not exclusively from homes.

PATIENTS:

Children and adults.

RESULTS:

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.

CONCLUSIONS:

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.