Notify Your Pharmacist About Dosing Devices That Have Nonmetric Units
July 2016
You'll hear more about the push to phase out NONmetric dosing units (teaspoons, drams, etc)...due to new reports of dangerous errors.
The most recent error occurred when a dosing cup was accidentally filled with 1 DRAM of concentrated morphine...instead of the prescribed 1 MILLILITER. There was a "1" line for both drams and milliliters on the cup...and the dosing UNIT wasn't double-checked.
The patient died after receiving almost four times the intended morphine dose...since there are 3.7 milliliters in 1 dram.
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