HLOL Podcast Transcripts

Health Literacy

Research About Using the Milliliter as a Standard Unit for Liquid Medication (HLOL #126)

Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month, and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some pretty amazing people. You will hear what health literacy is, why it matters, and how all of us can help improve health understanding.

Today, I’m talking by conference call with Dr. Benard Dreyer and Dr. Shonna Yin. Dr.  Dreyer is professor of pediatrics, Director of the Division of Developmental and Behavioral Pediatrics, and Director of Pediatrics at Bellevue Hospital. He also is a pediatric hospitalist at NYU Langone Medical Center.

Dr. Dreyer is very active in the American Academy of Pediatrics, or AAP, and co-chaired its Project Advisory Committee on Health Literacy. He also co-edited AAP’s book on health literacy for pediatrics called Plain Language Pediatrics. Dr. Dreyer serves on the Institute of Medicine’s Health Literacy Roundtable.

Dr. Shonna Yin is a general pediatrician and assistant professor of Pediatrics and Population Health at the NYU School of Medicine’s Bellevue Hospital Center. Among her many accomplishments, Dr. Yin researched the development and evaluation of low literacy strategies to improve parent understanding of medication instructions.

Both Dr. Yin and Dr. Dreyer are lead authors of an article called “Unit of Measurement Used and Parent Medication Dosing Errors” that was published in AAP’s Pediatrics journal. I found their research so fascinating that I invited both doctors to be guests on Health Literacy Out Loud. Welcome.

Dr. Dreyer: Thank you. I’m glad to be here.

Helen: Let’s start from the beginning. What does parent medication dosing errors mean?

Dr. Yin: There has been a lot of concern about how often parents make mistakes when they give medications to their children. Studies have found that about half of parents make errors dosing liquid medications.

Helen: What kind of mistakes?

Dr. Yin: They make mistakes in measuring the right amount of medicine, how often to give the medicine and how long to take the medicine.

Helen: Are these parents of young kids?

Dr. Yin: These are parents of children. Some of them are young and some of them are older. Many of the medicines that parents get confused with are liquid medicines because you have to actually measure out the right amount of medicine and that can be very confusing.

Dr. Dreyer: Many of the children are young, but some of them are older. Many kids can’t actually swallow pills until they’re older. Many over-the-counter medications that people buy are liquids.

Helen: Are these medication errors and mistakes just an inconvenience, or can this be all the way up to life threatening?

Dr. Yin: Serious things can happen when errors happen. Thousands of emergency department visits happen each year because of errors parents make in giving medications to their children. Luckily, most of the time there are not serious consequences, but serious consequences can happen.

Helen: You decided to look at this, so you must be seeing it in both of your practices a fair amount.

Dr. Dreyer: Yes. We see it in the emergency room here at this hospital. When we talk to patients and follow up about what medicines they’ve given to their children, often what they tell us is not really what we thought they were supposed to be giving.

Helen: Yikes. Tell us about your study and what you did. That’s a huge problem.

Dr. Yin: Let me give you a little bit of background about why we did this study. In order to simplify medication instructions and to reduce confusion, one strategy that’s being proposed is to have a standard system for talking about medicine doses with just one unit of measurement, the milliliter, be used by doctors, pharmacists and other healthcare providers who talk about liquid medicines.

Helen: Is that not happening now?

Dr. Yin: Exactly. Right now terms like teaspoon, tablespoon, dropperfuls, and milligrams are all used as part of medication instructions. If you think about one parent’s experience when their child is prescribed medication at a doctor’s visit, that parent may hear the amount in milliliters from their doctor.

Then they might hear the amount in teaspoons from their pharmacist. They might see something different on their prescription or on their medication bottle label. It isn’t a surprise that people can get confused. When the parent confuses one term for another, there can be multifold overdoses or underdoses.

Dr. Dreyer: Both can be a problem because giving too little medicine, especially with antibiotics, could prolong disease. Obviously giving too much of a medicine could cause serious side effects.

Dr. Yin: Exactly. In addition, words like teaspoon and tablespoon can be confusing because they seem to support the idea of a parent or a patient reaching into the kitchen drawer and grabbing any spoon. We know that kitchen spoons vary a lot in their size and shape and they really shouldn’t be used for dosing medicines. That’s why we recommend using standard dosing tools.

Helen: I’m thinking of my kitchen drawer. I’ve got all manner of different spoons in there. If I was pretty desperate to give a young person some medicine, I might just reach for the closest one there. Your study looked at milliliters as a standard unit of measurement. Is that correct?

Dr. Yin: Exactly. There has been this push at a national level to move toward this single standard unit, the milliliter, and groups like the CDC and the FDA, among others, are taking the lead on this.

There have however been concerns that moving to a milliliter system might actually create more confusion because parents and patients are used to dosing in teaspoons and tablespoons. Part of the reason we did our study was to look at whether that’s the case.

Helen: You’re going from something that was familiar and comfortable, that may not be accurate, to something new. For those of us who aren’t great with metric measurements, how much is a milliliter compared to a teaspoon?

Dr. Yin: One teaspoon is equal to five milliliters.

Helen: You’re multiplying something perhaps times five, which isn’t an awful mathematical function, is it?

Dr. Yin: It can be very confusing.

Helen: We know the abbreviation for teaspoon may be tsp., but what is the abbreviation for milliliter?

Dr. Yin: Usually it is mL.

Dr. Dreyer: Most of the European countries are on the metric system. Most of them have in fact been using milliliters. As Dr. Yin said, there’s been a little pushback in this country because we are not on the metric system, so people have felt that people will be uncomfortable using terms like milliliters.

Helen: Is that the biggest resistance, that people are just uncomfortable?

Dr. Dreyer: I don’t think that people are uncomfortable. I think that the experts who make these decisions are concerned that they might be uncomfortable. You’ll see when Dr. Yin tells you the results of our studies that it’s actually probably not the case.

Helen: Tell us. What did you find?

Dr. Yin: We did a study in two public hospitals in New York City. We had about 300 parents in our study. We enrolled parents who spoke English or Spanish who were prescribed liquid medicines by their doctor in the emergency department. We talked to the parent when they finished giving the medicine to their child and asked them questions about the amount of medicine they would give.

We wrote down how they talked about the medicine, whether it was in teaspoons, tablespoons, milliliters or some other way. We then had parents come back to the hospital to show us the amount of medicine that they gave. We also were able to look at the child’s hospital record to see the amount of medicine that was actually prescribed.

Then we compared what was prescribed to what the parent said their child’s dose was and the amount the child’s parent measured for us to see if there were any errors.

Helen: What did you learn?

Dr. Yin: We found that many parents were making errors in dosing medications for their children. About 40% of parent made errors.

Helen: Whoa! That’s a lot.

Dr. Yin: Yes, that’s a lot. Parents who thought of their child’s dose in teaspoons and tablespoons had twice the odds of making a dosing error compared to parents who dosed using milliliters only.

Helen: Wow. I’m just curious. Do people just have to go find their own implement to give their child liquid medicine or could they use one of those dosing tools?

Dr. Yin: They could use whatever instrument that they wanted to. If their doctor had given them one, they could use that. If they had one at home, they could have used that. What was interesting was that parents who thought of their child’s dose in teaspoons and tablespoons were actually much more likely to use kitchen spoons to dose.

Helen: Why do you think that is?

Dr. Yin: It’s probably related to the fact that when you say the word teaspoon or tablespoon, you’re much more likely to reach for that kitchen spoon.

In our case, those who thought of their child’s dose in teaspoons and tablespoons, about 30% of those parents used a kitchen spoon to measure their child’s medicine. Compared to those who thought of their child’s dose in milliliters only, only about 1% of that group used a kitchen spoon.

Helen: My head is just whirring with that song “A Spoonful of Sugar Helps the Medicine Go Down.” It just sounds so warm and fuzzy to have a teaspoon of something versus something that sounds so clinical and abstract like a milliliter. I don’t know if people have a visceral reaction to that like I do, but certainly we need accuracy.

Dr. Dreyer: Five milliliters of sugar make the medicine go down. Say that enough to yourself and it will sound warm and fuzzy.

Helen: All right. You’re finding that there are a lot of errors there. Is this for everybody, or is this tied into health literacy somehow?

Dr. Yin: We found that people who had low health literacy and those who were not English speakers were much more likely to make errors. However, there were high rates of errors across the board regardless of literacy level and whether or not they spoke English.

Dr. Dreyer: The answer is yes, having lower health literacy makes you more likely to make an error. The other part of that is that we all make errors. Parents who were not low literacy also had a reasonably high rate of making errors, not as high as those with low health literacy, but nevertheless very significant.

Helen: On the flip side, you found that those who were using milliliters consistently were more consistent and accurate in the dosing?

Dr. Yin: Exactly. They were much less likely to make errors.

Helen: There was a point you raised earlier that was concerning to me. You said that different people use different terminology, like the label can be different from what the doctor says versus what the pharmacist says. That seems like a problem unto itself.

Dr. Yin: Exactly. It’s something we also found in our study. We were able to compare the dose that was written on the prescription to what was written on the bottle label.

We found that about one in three prescriptions was different from what was on the bottle label. Either one unit was changed to something different or an additional unit was added when the prescription got to the pharmacy.

Dr. Dreyer: There are no regulations that say that a pharmacist has to dispense a medication exactly as the doctor wrote it. They have the option to do what they think might make it clearer to the patient for whatever reason. They can change it as long as the dose is the same.

Helen: Earlier you talked about pushback and about going from something more familiar to less familiar. Is there pushback why a pharmacist might have a different recommendation than a physician?

Dr. Dreyer: I don’t think we know. We haven’t actually interviewed the pharmacists yet. Part of what we need to study is why pharmacists might change from milliliters to teaspoons. My suspicion is that they think, “This person will understand that better. It’s five milliliters. That’s the same as a teaspoon, so why not say teaspoon?”

I also think that pharmacists want to do the right thing. Pharmacists are a very important part of the healthcare system. They’re out there dispensing the medication. They have the opportunity to actually educate parents about exactly how to give the medicine to the child, so we want to involve them as part of the solution to these problems with errors.

You heard from Dr. Yin that the Centers for Disease Control, has an initiative to decrease medication errors in children called the Protect Initiative. At that table, there are pharmacy and pharmacy leaders sitting around discussing these issues with us.

Helen: Thanks. I would imagine part of the team is not just physicians and pharmacists, but also parents who probably also very much want to do the right thing by their child.

Dr. Dreyer: Of course. None of the parents that make errors are necessarily being careless. We are concerned that they’re being confused by the way we communicate to them both verbally and on labels. A lot of labels are very confusing, and it’s certainly confusing when things get changed from one person to another.

Helen: It sounds like there are many possible points of confusion. Can we move on to the better news? What do you recommend based on your findings?

Dr. Yin: We hope that listeners recognize that parents and patients are often confused about how to measure medications correctly and that lack of standardization around units of measurement is one reason why. If you’re someone who prescribes medications, try to be consistent in the way that you talk to parents and how you write the dose on the prescription.

Use terms like milliliters instead of teaspoons or tablespoons. Be aware that someone might change the unit at the pharmacy, so be sure to let your parents and patients know that this is something that might happen. Make sure your parent really understands the medication instructions by doing teach-back and demonstrating the dose if possible.

Helen: That teach-back recommendation comes up all of the time.

Dr. Yin: Absolutely. Then give a parent or patient a standard dosing tool to take home.

Dr. Dreyer: We would like both prescribing physicians and pharmacies to always give families standard dosing tools to take home with them.

Dr. Yin: By standard dosing tool, we mean something like an oral syringe that you’re not able to put a needle on, a dosing cup, a dropper, or something that has markings on it to really guide you on how to measure out medication correctly.

Helen: That’s great. It sounds like that’s a wealth of recommendations for those of us who are coming at this as parents, grandparents, someone else responsible for helping to dose a child’s medication, as well as the professionals out there.

I was really wowed by that article. What you have uncovered was news to me. That’s why it grabbed my attention. It seems like a reasonable difference we can make if we just communicated consistently and clearly. Even in this issue about measurement, we can make things incrementally better.

Dr. Dreyer: Absolutely. We know that when we do interventions and explain things clearly to parents, they make many fewer errors. Dr. Yin can describe another experiment we published where we actually provided families with pictogram instructions on how to dose medications and showed that that 50% error has really dropped dramatically.

Helen: With pictures?

Dr. Yin: Yes. These pictures help show exactly how much medication to dose within a dosing instrument. We also have pictograms that show how to prepare, store and use the medication. Using pictograms in combination with a doctor doing teach-back, doing showback demonstration and giving a dosing instrument all can support a parent as they are measuring medications for their children.

Helen: Thank you. You both are embodying those principles of health literacy. Teach in all the ways that work, whether it’s pictures or dosing instruments, certainly using consistent language, and making sure that people really understand.

Dr. Dreyer: I want to make one last point. The concerns that people have raised about the use of milliliters which you described earlier, that this is not something people are used to or that this may be more confusing, I think one of the important findings of this study is that that was not at all the case.

On the contrary. Those who use or thought of doses in milliliters were much less likely to make errors and were much more accurate in their measurement and were much less confused. I think this shows that the American public as a group really does not have any problem with using the concept of milliliters rather than teaspoons and it could be easily adopted by parents around the country.

Helen: Thank you both for championing that. I’ve just learned so much from listening to both of you.

I also want to tell our listeners that there are plenty of resources we’re going to have on the Health Literacy Out Loud website, including the article of yours and a few of the references that you mentioned. Those will be on www.HealthLiteracyOutLoud.com.

Thank you both so much for being guests on Health Literacy Out Loud and even more for doing all you do. Thank you.

Dr. Yin: You’re very welcome.

Dr. Dreyer: It’s our pleasure.

Helen: As we just heard from Drs. Dreyer and Yin, health literacy isn’t always so easy. For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. You can find us on iTunes, Stitcher Radio, and the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.com. Subscribe for free and hear all the podcasts.

Did you like this podcast? Even more, did you learn something new? I sure hope so. If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.


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