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SAFER PRACTICE NOTICE Medication Cups – Product Change Issue Institute for Safe Medication Practices (ISMP) reported a fatal error in 2015 when the nurse confused drams as mLs . JULY 2nd 2016 Best Practice Drug Shortage Label change Medication Change Recall Vendor Change For the information of: Patient Care Managers Professional Practice Leaders Clinical Nurse Educators Nursing Staff Pharmacists Clinical Leads Contact: Medication Management Safety Team: Medication.Management@ covenanthealth.ca Goal of this best practice is to use liquid medication dosing devices that only display volume using the metric scale. ISMP has received more than 50 reports of mixups between milliliters (mL) and household measures such as drops and teaspoonfuls, some leading to injuries requiring hospitalization. Oral syringes,dosing cups, droppers, and other measuring devices have been involved. Use of the apothecary system has also caused confusion with mix-ups between drams and mL and other non-metric measurements such as ounces and tablespoons. ISMP first reported confusion in 2000, and has continued to receive reports of medication errors because of mix-ups between metric and non-metric units of measure. Covenant Health supports the use of medication cups (metric scale) for measuring medications that do not require critical or exact doses (e.g. Amagel) and oral medication syringes for critical and exact dosing. Action Patient Care units to order medication cups with mLs only – Medline Canada Corporation, Oracle Number 314671, Manufactuer Item DYND 70000. Med cup with numerous doses Med cup with mLs only Medline DYND 80000 Medline DYND 70000 Note: Automatic substitution occurring in the Central Warehouse. CPSM Notification of Product Change has been released Please Post *Adapted from ISMP National Alert Network (NAN ALERT) June 30th 2015