Dosing For Dummies

  • by: |
  • 10/19/2007
Instead of banning medicines, how about banning people from using drugs until they can follow directions. These are actual cases of how people used OTC and Rx drugs from the Oklahoma Poison Control Center.

Dosing cup errors accounted for 3.8% of all therapeutic errors, but was the fifth leading cause for errors in the less than 5 year-old patient group. The most common reasons for therapeutic errors in all age groups involved taking or giving the wrong formulation or concentration, inadvertently taking/giving medication twice and another incorrect dose. Typical examples of some of these errors are as follows.

Incorrect Formulation or Concentration:

1. A mother mistakenly gave 2.5 ml of lindane 1% shampoo to 6 month-old, 20 pound child instead of promethazine DM cough syrup due to similarity in the appearance of the bottle.
2. A mother gave 2 ml of a sibling’s baclofen suspension instead of acetaminophen syrup to her 8-month-old son.
3. A grandparent gave 5 ml of Benadryl ® Maximum Strength Itch Stopping Gel 2% to a 10 year-old child after being instructed by parents to give the girl her dose of “Benadyl ® syrup”. Final dose of diphenhydramine equaled 100 mg instead of 12.5 mg.
4. Four capsules of Hartz Mountain ® Dog Wormer containing piperazine adipate were taken by a 42 year-old woman instead of 4 diphenhydramine 25 mg capsules for sleep. She also gave 4 capsules to her 15 year-old son as well.

Other Incorrect dose:

1. Parents misunderstood prescription directions and double dosed 10 year-old daughter’s dextroamphetamine sulfate® 10 mg for two weeks.
2. Parents gave 2 year-old daughter doses of Tylenol® Syrup for Children and Dimetapp® Nighttime Flu for 3 days before checking the labels and finding acetaminophen in both products.
3. Alendronate sulfate 70 mg was taken daily for 3 days instead of once weekly for 3 weeks by 86 year-old cardiac patient.
4. Six tablets of Triphasil® birth control pills were taken at one time because 34 year-old woman has missed 6 of her doses.

Maybe we should cough medicines for children under the age of 34.

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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