American Academy of Pediatrics (AAP)1

J u n e 3 0, 2 0 1 5 A fatal event was reported recently to the ISMP National Medication Errors Reporting Program in which a nurse confused two dosing scales that appear on a plastic oral liquid dosing cup. It has an archaic measure— drams (fluid drams)—which the nurse confused as mL. This particular dosing cup is commonly used in US healthcare facilities today (Figure 1). Many healthcare professionals are familiar with mix-ups that have occurred when measur-ing doses of liquid medicine using dosing cups, sometimes causing seri-ous medication errors. To prevent mix-ups between variable measure-ment systems, multiple national organizations have called for the adoption of the metric system (milli-liter) as the standard for prescribing and measuring doses of liquid medica-tions. These organizations include the