Choosing Wisely:

Don’t prescribe or administer oral liquid medications using teaspoon or tablespoon for measurement; use only mL when measuring with an approved dosing device (e.g., medication cup or oral syringe).

Rationale and Comments: Serious medication errors, including patient deaths, have occurred because oral liquids are prescribed and/or administered using English measurement units such as the teaspoon or tablespoon. For medical professionals, best practice is using units and volume when prescribing a single-agent liquid medication, to be sure the dose is clear; but for administering, use only mL for measuring the amount. Safety organizations and agencies such as the CDC and the Institute for Safe Medication Practices have recommended using only the metric system units (e.g., mL) for measurement and using a measuring device that contains only metric markings. Prescribing using the metric system and dispensing with a metric measuring device will help avoid these preventable errors.
Sponsoring Organizations:
  • American Society of Health-System Pharmacists
  • Sources:
  • Expert consensus
  • Disciplines:
  • Pediatric
  • References: • Varkey, P, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 2007; 64:850-5.
    • Najafzadeh M, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Am J Manag Care 2016; 22:654-61.
    • Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014; 48:1298-1312.
    • The Joint Commission. 2017 National Patient Safety Goals [Internet; cited 2017 Jan 21]. Available from: www.jointcommission.org/standards_information/npsgs.aspx.

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