We occasionally see pharmacy dispensing errors in the NICU population where the dose is drawn up instead of the volume. Both are prominent on the Epic label. We've asked to have them put on separate lines but were told that wasn't possible.

Usually these involve 10-fold errors involving very low volumes... so for example PO clonidine: The dose is 1.7 mL and the volume is 0.17 mL.

Since we don't have any technology in place that can detect this type of error on PO meds, I'm pretty concerned.

We've considered concentration changes to avoid 10-fold dilutions. That can result in the need to have 2 different concentrations (for very small vs very large babies), which gets complicated to build. I've wondered if there's been any recommendations not to use 10 fold concentrations for NICU meds due to potential mix ups, but I haven't come across anything that support that. I'm not sure that it would completely mitigate the situation.

We do encourage techs to circle the Volume on the label, which is sometimes done.

Has anyone else noticed this type of error? What have you done to prevent it? Any other ideas?

Thanks