ASHP, a national professional organization for pharmacists, and the Institute for Safe Medication Practices have issued a National Alert for Serious Medication Errors that recommends hospitals use liquid medication cups that measure in metric.
The national alert comes after a fatal event at a hospital, reported to the ISMP National Medication Errors Reporting Program, in which a nurse confused the dosing scales between fluid drams and milliliters on a plastic dosing cup. That confusion led to an overdose of morphine sulfate, and the patient died.
To avoid such errors in the future, ASHP and ISMP recommend that hospitals use oral syringes that measure only in mL whenever possible. When a cup has to be used instead of a syringe, it too should only measure in mL. However, the organizations note that such cups are not widely available at this time.