Hi all,

We have noticed a trend in reported errors related to dosing unit mix ups within our children's hospital. an example of a potential mix up would be something like ordering mg/kg/day when it really should be mg/kg/dose and so on. For background, we have set up the system for order sets to default to the appropriate dose and dosing unit but this may not be the case when medications are ordered "a la carte" (i.e. from the medication preference list).

We are an Epic institution and the children's hospital is located within an adult hospital. One potential solution I have seen from other organizations is to utilize Tallman lettering to better call the difference between dosing units (i.e. mg/kg/DAY, mg/kg/DOSE, mg/kg/HOUR, etc). My specific questions are:

1.) Has your organizations seen similair errors reported and have implemented Tallman lettering for dosing units? If so, has this been successful?

2.) if you have implemented Tallman lettering for dosing units and it was NOT successful, have you implemented another strategy?

Thank you!