Clinical Tip: Replace the teaspoon with a measuring device

November 1, 2008

Due to the inherent risk of dosing errors, teaspoons should be eliminated from a pediatrician's vocabulary.

A recent study involving a large number of pediatricians (148), pharmacists (55), and caregivers (398) revealed that over 50% of children's liquid medication prescriptions were written, filled, and administered by teaspoon rather than by milliliter. The blame for this potentially serious dosing error was found to be equally shared by the pediatricians, pharmacists, and caregivers.

The volumes of the 53 teaspoons brought in from home by doctors and nurses varied from 4.2 milliliters to 12.9 milliliters. Only one teaspoon measured exactly five milliliters. These teaspoons appeared to be the same size, but in fact, varied tremendously in volume, suggesting a serious potential for overdosing.

These results should serve as a strong reminder to all pediatricians to eliminate the teaspoon from their vocabularies when ordering or suggesting liquid medication for their patients. Caregivers should be taught to only administer liquid medication to their children by milliliter, using a measuring device.