Consider the following real-life scenarios:

These real and serious cases—one resulted in a child’s death—illustrate a small sample of liquid dosing errors that have been reported to the Institute for Safe Medication Practices (ISMP). The ISMP has received at least 50 reports of just 1 type of error, confusing milliliters with teaspoons. The reports provide a window into how easily nonstandardized dosing can compromise medication safety and have spurred a public-private effort to standardize liquid medication dosing for products obtained at community pharmacies.