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ISMP Medication Safety Alert

Caution! Dose cups that come with nonprescription drugs are unique for each product

Those pesky dose caps on nonprescription medications strike again! A 56-year-old woman accidentally took two doses of Pepto-Bismol® liquid because she thought that the dose cup held one dose, but it actually held two doses. Luckily, it's not very concentrated, and that amount was not an overdose for her. In a similar case, a mother gave her 2-year-old son four teaspoons of children's acetaminophen elixir because the label said to give one dose. Thinking that the dose cup held only one dose, she gave him an entire dose cup. Again, although it was more medication than he needed, it was not an overdose. The last case has a different twist to it: a mother gave her 5- year-old son Dimetapp® elixir, but she mistakenly used the dose cup from another medication. She gave him three teaspoons instead of one teaspoon, which was just shy of an overdose. Dose cups seem to create more problems for the convenience they offer. We recommend that you keep the dose cup together with the OTC medications it came with because there is no standard size or markings for dose cups. You can also ask your pharmacist for an oral syringe, which is even more accurate.

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