Search

Self Care Pharmacy Blog

Archive for December, 2014

 

Weighing in on Liquid Measurement Error

Friday, December 5th, 2014

By Bryan Feldmann, PharmD student

If someone were to ask you what the difference was between a teaspoon and a tablespoon, would you know what to say? You might have prescriptions from your doctor or medications you bought over-the-counter that tell you to take a number of tablespoons or teaspoons of the medication. A teaspoon will usually be abbreviated as “tsp” and tablespoon as “tbsp.” Because the two abbreviations look very similar, it can be easy to mix them up at a first glance. This can be a big problem, because it is so important that meds are taken exactly as directed.

You may already know what teaspoons and tablespoons are, but many people do not. Tablespoons and teaspoons are two different units of measurement. Similarly to gallons and liters, teaspoons and tablespoons are both used for determining how much volume something has (in other words, how much space it takes up). You will usually see units of volume used when your medication is a liquid.
So, how do these two similar units of measure differ? To begin, a teaspoon is smaller than a tablespoon. You can remember this by thinking of how big a table is compared to a cup of tea. In fact, tablespoons are three times larger than teaspoons. Now, just think about how dangerous it might be if someone accidentally took three times the amount of drug they were supposed to by mistake. According to a new study published by the American Academy of Pediatrics (medical care of children and teens) there are more than 10,000 calls to the poison control center every year because of errors patients made in how much of a liquid medicine they took.1 Just imagine the horror of the parents and caretakers being forced to call the emergency number because of an adverse reaction to a medication error. Since liquid medications are usually given to children, the study also specifically measured how many times parents made a mistake when pouring medicine for their kids. When they were supposed to measure with either teaspoons or tablespoons, they accidentally measured incorrectly 40% of the time, or 2 out of every 5 times!1 What can be done to fix this?

Teaspoon (tsp) and tablespoon (tbsp.) look so alike it is no wonder people can mix them up, but there is another common way to measure volume— the milliliter, or “mL.” A milliliter looks and sounds nothing like a teaspoon or a tablespoon, so it would stand to reason that people would not confuse it with anything else. There are 5 milliliters (mL) in a teaspoon, meaning there are 15 mL in a tablespoon.2 So milliliters are also useful for being more precise, since not everything must be in multiples of 5 milliliters. In another study, parents who had to measure medications in teaspoons or tablespoons were compared to those who measured in milliliters.3 The parents who were asked to use teaspoons and tablespoons were about twice as likely to make a mistake.3 287 single parents or pairs of parents were studied to get these results.3 This is a very small sample when compared to how many parents there are giving medications to children in the country, so more research should still be done.

Just mixing up the units is not the only reason these forms of measurement are so problematic, however. Many homes have kitchen teaspoons and tablespoons spoons just for measuring in teaspoons and tablespoons, but a study in the International Journal of Clinical Practice showed that the spoons that people have differ drastically from one another and are not accurate.4 Another study, published in the Archives of Pediatric and Adolescent Medicine, which is itself published by the American Medical Association, found that oral syringes and droppers are the best tools to use to measure volume and avoid error.5 300 parents were asked to measure out one teaspoon of acetaminophen with dosing cups, dosing spoons, oral syringes, and droppers. 70% of the parents made an error when it came to using the dosing cups with printed markings, and 50% made an error when using dosing cups with etched markings. More than a third of just these mistakes alone would have been highly dangerous overdoses if this study were not conducted in a controlled environment. According to the Institute for Safe Medical Practices’ reporting on this study, “Parents who make mistakes when using dosing cups are often confused about the differences between teaspoons and tablespoons.”6 Mistakes were only made 6% of the time when using a dropper, 10% of the time when using an oral syringe, and 14% of the time when using a dosing spoon. Keep in mind that a dosing spoon is different than a kitchen teaspoon or tablespoon, in that it is accurately calibrated to hold the amount it purports to, unlike the others, which have been shown to vary from spoon to spoon. So we can rest assured that it would be much safer to measure a number of milliliters in a liquid measuring device such as a dropper instead of simply trusting in one of these spoons. Additionally, it is not very easy to measure the exact amount of medication such that it is lying flat at the brim of the spoon without making a mess. This could be much easier if a dropper or oral syringe was used.

It would be great if milliliters replaced teaspoons and tablespoons on all drug labels over time, but at the moment we will likely continue to encounter all three units of measure. Armed with the knowledge of how much each unit represents and being careful when you’re reading instructions will decrease your chances of committing a liquid medication measurement error. As a future pharmacist, I would recommend always using a measuring cup or another device such an oral syringe over a spoon to measure tablespoons and teaspoons, even if the spoons say they are designed specifically for that purpose. Share these important tips with friends and family and always be careful in order to guarantee positive outcomes for yourself and your loved ones. And if you are a health care provider follow the link here to see ISMP’s recommendations for preventing liquid medication errors.

Have you ever mixed up tablespoons and teaspoons? Have you seen someone else mix them up? What steps will you take to avoid liquid medication mistakes?

References

  1. Schmidt C. Child medication measurements confuse parents. cnn.com  http://thechart.blogs.cnn.com/2014/07/14/child-medication-measurements-confuse-parents/. Published July 14th, 2014. Accessed November 6, 2014.
  1. Teaspoon v. tablespoon: What’s the difference? Ismp.org https://www.ismp/org/consumers/teaspoon.asp Updated 2014 Accessed November 6, 2014
  1. Yin H, Dreyer B, Ugboaja D, et al. Unit of measurement used and parent medication dosing errors. American Academy of Pediatrics. 2014;134(2).
  1. Falagas ME, Vouloumanou EK, Plessa E, Peppas G, Rafailidis PI. Inaccuracies in dosing drugs with teaspoons and tablespoons. Int J Clin Pract. 2010;64(9):1185.
  1. Shonna Yin H, Mendelsohn AL, Wolf MS, et al. Parents’ medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164(2):181-186.
  1. Use an oral syringe or dropper to measure children’s medicines, not a cup.ismp.orghttps://www.ismp.org/newsletters/consumer/Issues/20100105.asp. Published June 2010. Accessed 12/02, 2014.

Lather, Rinse, and Repeat

Tuesday, December 2nd, 2014

By Logan Conkey, PharmD Student

Students are in the swing of things now that fall has begun. Students are at a higher risk of spreading sickness to others because of the environment they are in.  October is here and this month initiates flu season as well as a time where more illness is being shared.1 To prevent the spread of illness, the CDC recommends cleaning hands frequently, including after using the restroom.2 Many people do not like to wash their hands and a survey reported by the American Society for Microbiology reported 1 in 5 teenagers and adults claimed they do not wash their hands after they use the restroom.3 With so many germs being passed around, students often become sick and have to miss school. Recently, a group of researchers in New Zealand wanted to see if there was a relationship between the amount of school days missed due to illness and hand hygiene that included hand sanitizer combined with normal and frequent hand washing.

CNN Health published the article; Hand sanitizer doesn’t help in schools in August this year.4 The article was based on a study that took place in elementary classrooms in New Zealand and compared students who hand washed only and students using alcohol based hand sanitizer along with normal hand washing. All classrooms were taught proper washing techniques to ensure a standard practice and the alcohol sanitizer was provided to make certain it was the same strength throughout. The trial was conducted in 68 elementary schools, during the winter term, with children ages 5-11 The control group was instructed only to use regular hand washing with soap and water when cleaning their hands. The intervention group was instructed to wash their hands with soap and water and include the use of an alcohol-based sanitizer after they coughed, sneezed, and before meals. The outcome was to be determined by comparing the amount of total days students missed due to illness only. The results suggested there was not a significant difference between the groups regarding total days missed. The study did not look at specific illnesses such as flu when collecting data and the study may have been limited because there was a flu epidemic during this season. Another limitation included parental direction and whether the parents were instructing students to differ from the provided procedure. Some students also complained about the taste of the sanitizer on their hands when eating and this believed to have made the children less compliant when using it. The complaints came from a handful of schools and the sanitizer was replaced with an equivalent.5

The CDC says hand washing with soap should be the first option and hand sanitizer should be used if soap and water are not available. Alcohol-based sanitizers do not eliminate all forms of germs.6 It is confirmed that proper hand washing and/or the use of alcohol-based hand sanitizers has shown to reduce the risk of infection from certain viruses.7 Alcohol based sanitizers must be strong enough to be effective. Not all sanitizers are created the same and the recommended strength should be at least 60%.8 Other studies performed in the classroom regarding the used of alcohol based hand sanitizers has not persuaded researchers to consider them beneficial enough to place high priority on them and that hand hygiene education is the largest benefactor.9

The study performed in New Zealand provides proof we should not be putting a high priority on placing alcohol-based hand sanitizer in classrooms. Parents should encourage proper hand hygiene and instruct children when the most important times are to wash hands. If hand washing is not an option then hand sanitizer is a good second choice. While there does not seem to be a great benefit to sanitizer in the classroom, there have been no reported risks or problems with using it. The parent or teacher must decide if they want to incorporate sanitizer. There is no way of eliminating illness in children but parents and teachers can work together to improve the health of the classroom.

Are you and your students taking the proper precautions to prevent sickness?

 

References

  1. The Flu Season. CDC Website. Available at: http://www.cdc.gov/handwashing/when-how-handwashing.html. Accessed October 3, 2014.
  2. Preventing Seasonal Flu Illness. CDC Website. Available at: http://www.cdc.gov/flu/about/qa/preventing.htm. Accessed October 3, 2014.
  3. Hand Sanitizer doesn’t help in schools. CNN Health Website. Available at: http://thechart.blogs.cnn.com/2014/08/12/hand-sanitizer-doesnt-help-in-schools/?iref=allsearch. Accessed October 3, 2014.
  4. Bratsis M. Flu Season: The Best Defense. Science Teacher [serial online]. October 2012;79(7):68. Available from: Education Research Complete, Ipswich, MA. Accessed October 3, 2014.
  5. Priest P, McKenzie J, Audas R, Poore M, Brunton C, Reeves L. Hand Sanitiser Provision for Reducing Illness Absences in Primary School Children: A Cluster Randomised Trial. Plos Medicine [serial online]. August 2014;11(8):1-14. Available from: Academic Search Complete, Ipswich, MA. Accessed October 3, 2014.
  6. When & How to Wash Your Hands. CDC Website. Available at: http://www.cdc.gov/handwashing/when-how-handwashing.html. Accessed October 3, 2014.
  7. Prazuck T, Compte-nguyen G, Pelat C, Sunder S, Blanchon T. Reducing gastroenteritis occurrences and their consequences in elementary schools with alcohol-based hand sanitizers. Pediatr Infect Dis J. 2010;29(11):994-8.
  8. Roy K. Rethinking the use of hand sanitizers. Science Scope [serial online]. September 2009;33(1):74-76. Available from: Education Research Complete, Ipswich, MA. Accessed October 3, 2014.
  9. Meadows E, Le Saux N. A systematic review of the effectiveness of antimicrobial rinse-free hand sanitizers for prevention of illness-related absenteeism in elementary school children. BMC Public Health [serial online]. January 2004;4:50-11. Available from: Academic Search Complete, Ipswich, MA. Accessed October 3, 2014.

Electronic cigarettes: effective, or just the new “cool” sensation?

Monday, December 1st, 2014

By Samuel Tesfaye, Pharm.D. Student.

Electronic cigarettes (e-cigarettes) are becoming increasingly popular in the U.S. despite lack of evidence regarding their safety.1 According to the National Tobacco Survey, e-cigarette use in both the youth and adult population has nearly doubled from 2011-2012.2 Many smokers of conventional cigarettes are using e-cigarettes as an aid to help them quit smoking. Unlike conventional cigarettes that release smoke, e-cigarettes are battery-powered devices that deliver nicotine through emission of a vapor.3 The vapor within the e-cigarettes is generated by heating a solution made up mostly of propylene glycol or glycerol.1

Several reasons support this increased popularity of e-cigarettes, especially among the youth. E-cigarettes can easily be carried around in the pocket and come in a variety of different flavors, which makes them appealing to the user.3 There is also a “coolness” associated with e-cigarette use likely arising from aggressive advertisement of e-cigarettes on national TV and other social media.3 The lack of the appealing qualities in other treatment methods, such as nicotine patches, offers little incentive for youths to use anything other than e-cigarettes.

Because e-cigarettes are relatively new products, research on the long-term health consequences of these products is lacking. Despite this limitation, a few of the studies conducted have indicated that substances contained in the e-cigarettes are harmful to the body. Propylene glycol, the main ingredient of e-cigarettes, is one example of these harmful substances. When propylene glycol is heated, it forms propylene oxide, which has been linked to respiratory irritation, central nervous system impairment, and even various types of cancer.1

A recent article in JAMA Pediatrics evaluated the benefit of e-cigarettes in helping smokers quit.2 The researchers employed a cross-sectional analysis from the National Youth Tobacco Survey data (NYTS). The NYTS was conducted on a representative sample of US middle and high school students from all 50 states between 2011 and 2012. The number of students surveyed were 17, 353 in 2011 and 22, 529 in 2012. Respondents were asked a series of questions about their cigarette smoking habits and which product(s) they use (conventional, e-cigarette, or both). The researchers found that e-cigarette use did not discourage the use of conventional cigarettes. This suggests that e-cigarettes are not effective in helping smokers quit. Moreover, it was also found that e-cigarettes led to instances of nicotine addiction and an increased risk of switching to conventional cigarette smoking (for those who hadn’t used traditional cigarettes prior to e-cigarettes). This study is not without limitations, however. Because the survey was entirely self-reported, the information obtained may not be valid and accurate due to the fact that those who took the survey may not have been completely truthful. For instance, they may smoke more than what they reported. Additionally, their conclusion cannot be generalized to the general public because the sample only included middle and high school students.

Contrary to the findings in this article, one study has reported that e-cigarettes are effective in helping smokers quit. Some healthcare providers are even recommending e-cigarettes to their patients. A recent study conducted in North Carolina examined physician’s attitude toward the use of e-cigarettes.4 The researchers reported that over two thirds (67.2%) of the physicians indicated that e-cigarettes are a helpful tool for patients wanting to quit smoking.4 More surprisingly, 35.2% of physicians said that they have recommended them to their patients.4 This study tells us that e-cigarettes are gaining momentum not only among the public but also among health care providers.

Smokers wishing to quit have a variety of nicotine replacement therapy products from which to choose, including inhalers, lozenges, chewing gum, and nasal spray.7 Smokers can also use prescription medications such as bupriopion and varenicline, as these medications have been proven to be safe and effective.7 Maintaining a healthy support network is also one way smokers can quit smoking. Socializing with people, exercising, going to movies, and doing outdoor activities can help people quit smoking.8 Seeking professional counselling from a primary care physician or pharmacist might also help smokers quit smoking. Pharmacists can play a pivotal role in helping people quit smoking by providing patients with the health consequences of smoking and the benefits of quitting, as well as assisting the patient is selecting an appropriate nicotine replacement product. Given the number of number of smoking cessation options that have been proven safe and effective, until further research is conducted on the long-term consequences of e-cigarettes and their safety is established, I believe patients should refrain from using these products.

Do you think e-cigarettes might be an appropriate smoking-cessation aid for you, or someone you know who is wanting to quit smoking?

References

  1. Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: A scientific review. Circulation, 129(19) 72-86.
  2. Dutra L, Glantz S. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study. JAMA Pediatrics [serial online]. July 2014;168(7):610-617. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 24, 2014.
  3. Trumbo C, Harper R. Use and Perception of Electronic Cigarettes Among College Students. Journal Of American College Health . April 2013;61(3):149-155. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 21, 2014.
  4. Kandra, K. L., Ranney, L. M., Lee, J. G., & Goldstein, A. O. (2014). Physicians’ attitudes and use of E-cigarettes as cessation devices, North Carolina, 2013. PloS One, 9(7).
  5. Pepper, J. K., McRee, A., & Gilkey, M. B. (2014). Healthcare providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. Journal of Adolescent Health, 54(6), 678-683.
  6. S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2014 October 21].
  7. Electronic cigarettes (e-cigarettes). CA: A Cancer Journal For Clinicians [serial online]. May 2014;64(3):169-170. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 2, 2014.
  8. Glynn, T., & Manley, M. W. (1992). How to help your patients stop smoking: A manual for physicians.DIANE Publishing

Magnesium and physical activity – does it make a difference?

Monday, December 1st, 2014

By Matthew Johnson, Pharm.D. Student.

Magnesium is a mineral involved in many bodily functions such as muscle and nerve regulation, blood sugar control, energy production, and the making of proteins.Recommended Dietary Allowance (RDA) is the average daily amount needed to meet the body’s needs of a dietary substance for most healthy people.The RDA for magnesium varies by age and gender. For women 19-30 years old it is 310 mg (men 400 mg). For women aged 31 years and older the value is 320 mg (420 mg for males). A deficiency of magnesium can result in seizures, abnormal heart rhythms, low blood calcium and potassium levels, and muscle contractions/cramps. Furthermore, magnesium deficiency has been linked to both lower physical activity and exercise ability.2  This is even more important for the elderly population because of the impact the aging process has on physical activity.Specifically, the aging population is at greater risk for magnesium deficiency than young people due to low dietary intake, reduced absorption, and a greater amount excreted in stools and urine. It is important to note, however, that excessive magnesium intake from supplements may cause diarrhea, abdominal pain, and/or cramping. Furthermore, intake of amounts greater than 5000mg per day can lead to magnesium toxicity and death. 4

The current standard of care for improving physical activity is sufficient aerobic and muscle-strengthening activities.5  The Center for Disease Control and Prevention recommends for adults 65 years and older to do muscle-strengthening activities that work all of the major groups of muscles (hips, back, shoulders, arms, legs, chest and abdomen) on two or more days per week. Muscle-strengthening activities include lifting weights, resistance band usage, push-ups, sit-ups, yoga, and gardening activities such as digging or shoveling. The CDC also recommends that all adults 18 years and older get either 5 hours of moderate-intensity aerobic activity or 2 hours and 30 minutes of vigorous-intensity aerobic activity. Moderate activity is a 5 or 6 on a 10-point scale in which 0 is defined as sitting and 10 is full effort activity. Vigorous activity is a 7 or 8 on this same scale.

A study recently published in the American Journal of Clinical Nutrition looked at the effects of oral magnesium supplementation on physical performance.3  This study only involved healthy elderly women that were involved in a weekly exercise program. There were two groups of healthy women in the study: one group received oral magnesium supplements of 900mg magnesium oxide/day for 12 weeks while the second group did not receive supplements or any other differences in treatment. The purpose of the study was to see if magnesium supplementation would improve physical performance. Short Physical Performance Battery (SPPB) tests were used in part to examine physical performance. A SPPB test involves checking lower limb activities such as walking and balance. The study found better physical performance in the group taking the magnesium supplements. There were no harmful effects seen in either of the groups. One major factor that limited the results of the study was that it only included healthy elderly women that exercised and so the same results may or may not occur in populations such as adolescents, men, or people that do not exercise. A different study published earlier this year in the Journal of Sports Sciences supports the findings that magnesium supplementation can improve physical performance.6

For individuals seeking to improve physical activity, it appears that magnesium supplements in the appropriate RDA range can be taken to boost physical activity performance.  Have you tried magnesium supplements before? If so, what form did you take and did you notice any differences after taking them?

Sources:

  1. S. Department of Health & Human Services, Nation Institutes of Health, Office of Dietary Supplements. Magnesium Fact Sheet for Health Professionals. http://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/ Reviewed November 04, 2013. Accessed October 2014.
  2. Lukaski HC. Magnesium, zinc, and chromium nutriture and physical activity. Am J Clin Nutr. 2000;72(suppl):585S–93S.
  3. Nicola V, Berton L, Carraro S, et al. Effect of oral magnesium supplementation on physical performance in healthy elderly women involved in a weekly exercise program:a randomized controlled trial. Am J Clin Nutr. 2014; 100: 974-981.
  4. Kutsal E, Aydemir C, Eldes N, et al. Severe hypermagnesemia as a result of excessive cathartic ingestion in a child without renal failure. Pediatr Emerg Care. 2007;23:570-572.
  5. Center for Disease Control and Prevention. Physical activity: How much physical activity do older adults needs? http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html. Updated June 17, 2014. Accessed November 2, 2014.
  6. Setaro L, Santos-Silva P, Colli C, et al. Magnesium status and the physical performance of volleyball players: effects of magnesium supplementation. Journal Of Sports Sciences[serial online]. March 2014;32(5):438-445. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 12, 2014.