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Brain between your ears, not in the palm of your hand

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This entry is dedicated to all of the PA’s and NP’s out there who use a hand-held device (palm pilot, iphone, whatever) to dose medications.


Lets be completely honest here. We are both professionals so we can have this conversation.  Do you really think a welfare mother of 4 is going to have the mental horsepower to measure anything other than what is clearly marked on a measuring spoon?  Do you think they can comprehend the idea of anything smaller than 1mL?  Do you really believe in their ability to use a dosing syringe and draw up liquid to a big black line which I draw on there with a sharpie?


If you cannot use some common sense and round up or down dosages of amoxicillin or Prelone to either 1/2 or 1 full teaspoonful, then please save us both the trouble and write for something else which can.  Seeing dosages of 435mg tid of amoxicillin suspension just makes me wish that you didn’t have prescriptive authority.  I’m just going to round up to 500mg, and when you call me to bitch, I’m just going to tell you to use a little common sense and less calculator.  I’m also going to tell you that the idiot mother in front of me (who has yes to realize that penis + vagina = kid) doesn’t have a snowballs chance in hell in measuring what dose you initially wrote for.

Idiots who write super-precise dosages like that are the retards in college that score 100% on the tests, but can’t apply that knowledge to any real-world situation to save their life.  Unless you are dealing with a hospital staff with very narrow therapeutic drugs, whats the point of writing dosages like that?  Are you proud that you can do math using mg/kg units?  Are you proud that you have a program that figures out the dosages for you?  Have you ever in your life seen the thick pink amoxicillin death that you wish to be dosed out to .004mL digits?

When you write for those dosages, think for a whole 2 seconds knowing that amoxicillin comes in 125mg/5cc (1 cc = 1 mL in case you didn’t know), 250mg/5cc, and the ever not-used 400mg/5cc.  Now, use your math skills and shoehorn the dose that the stupid palmpilot program gives you into one (1) of those dosage bottles so the twatmuffin mother will give 1/2 or 1 teaspoon.  If you can’t, then just round up.  If some kid dies from getting an extra 25mg of amoxicillin, then obviously your diagnosis was so far off you shouldn’t be practicing.

Finally, please, when the pharmacist comments on your dose over the phone, don’t just blow him/her off with a “uh huh” and proceed to write again for stupid dosages.  That just makes us angry (and you get a rant written about you).

Comments #

Comment by ER’s Mom on 2009-03-22 07:03:00 -0700 #

God, it makes me glad that I don’t do peds. Give me my Keflex, Macrodantin, Cipro, Flagyl, Zithromax and Bactrim standard doses, please.
I can’t remember when I gave an antibiotic that wasn’t one of the above!

Comment by Adam on 2009-03-22 07:31:50 -0700 #

There’s a children’s hospital in the city I work that likes to write for EXACT dosages… 6.85ml of amoxicillin per dose… I always laugh when I’m consulting with the patient and tell them to round to 7. I’m not sure where these prescribers think we get our measuring syringes from, but they aren’t the same exact-to-the-hundreths-place syringes we used in chem-class. Average person intelligence to measure these rediculous amounts out needs to be considered, too.

Comment by Adam on 2009-03-22 07:34:19 -0700 #

Unrelated, but just wanted to let you know that Solodyn has a generic available now…

Comment by anonymous on 2009-03-22 08:19:26 -0700 #

That’s what pipettes are for

Comment by Mmhmm on 2009-03-22 09:28:36 -0700 #

Agreed. Nothing worse than having a parent call us on a weekend 3 days after getting 10 days worth of medication and stating we didn’t give her enough to last the treatment because she is giving it just as prescribed and is already out. After investigation we find she obviously has been giving 43 milliliters per dose as opposed to 4.3 or some such nonsense. (hypothetical numbers people)
On a side note: I’m really suprised that you don’t see alot of 400/5 dosing. I’d say that dose is probably our most commonly dispensed strength. Location means everything when it comes to what is dispensed I suppose.

Comment by Shalom (R.Ph.) on 2009-03-22 14:43:21 -0700 #

I also see far more 400/5 than all the other strengths combined. You could float a boat in the amount of Amoxil 400 that goes out of here in a typical week. The pediatricians around here are on a low-volume kick; their argument is that the less you give, the less chance there is of it being spat out or thrown up. Of course measuring half as much means you’re that much more likely to get the “you shorted me!” calls, because nobody knows what a half teaspoonful is. Or worse, they use the schnapps cup that they throw in with the Tylenol suspension and try to fill it up to the line that says “1/2 tsp” which is about 1mm above the bottom. Can you say “meniscus error”, boys and girls? I didn’t think so.
Of course this can have its downside, too. One of the MDs here likes to write for Suprax (and why there’s no generic even though the patent ran out years ago is a rant for another time). Y’all know what *that* costs, and two of the local Medicaid plans won’t cover it without prior auth. Also those who have the 50% coinsurance or who pay out of pocket aren’t all that happy with it either. So when I see a doctor write for Suprax 200/5, sig tsp 1/2 qd x10, discard remainder, I’ll get on the phone and try to convince them to change it to the 100/5, sig tsp i qd, so they won’t be throwing out $100 worth of abx. Yes it’s harder to get the child to take twice as much liquid, but if the dad hasn’t got the gelt in his pocket to pay for it, the kid’s not going to take it at all.
As for the contents of your rant: Preach it, brother. Just last week I got a prescription for some weird amount like 4.7ml. He asked what that was, and I said basically it’s a tiny bit less than a teaspoon, and if you measure a teaspoon it’ll be so close that nobody could tell the difference. I haven’t seen anything with three significant figures after the decimal point *recently*, but I have seen them…
Public service announcement, totally unrelated to the above: Those of you who work in independent pharmacies where you have to watch your reimbursements like a hawk to make sure that you didn’t take a loss:
Changes in NDC can lead to big changes in reimbursement. Prevacid, for example, has recently changed NDC prefix from 00300- to 64674-. Along with this has come a huge jump in both acquisition cost and AWP. If you bill under the old number, the 3rd-parties will happily reimburse you under the old AWP, regardless of whether it’s way under your current cost. We’re talking a buck and a half per solutab, here, it makes a big difference in a month’s supply. Concerta has likewise switched from 17314- to 50458-, and while the difference in AWP isn’t as huge, it’s still quite a bit higher. If you have the ability to inactivate obsolete NDCs in your computer system, I suggest you do so to prevent someone from inadvertently billing the old number.
(Now of course everyone out there is laughing at me and saying “Good morning! You just realised this?” but if it helps someone who didn’t notice the change, I don’t mind looking like an idiot.)

Comment by RxRoo on 2009-03-22 14:59:05 -0700 #

I think it’s even funnier when it’s so stinkin’ close to a whole number. I’ve had NPs write for 1.93 mls of Zithromax suspension. Now, do you really think that 0.07 mls of 200mg per 5 ml liquid is going to make a difference???? I round and don’t even bother calling to tell them that I did. Why waste both of our time? At least I’m considerate. 🙂

Comment by rph3664 on 2009-03-22 18:41:43 -0700 #

The retail area at the hospital where I work dispenses a lot of amoxicillin 400/5. They do more Augmentin, really, but that’s what the peds here order.
Now, when you’re talking pediatric doses for Viagra, hydralazine, chlorothiazide, digoxin, etc. THEN I can understand exact dosing, because it’s critical that the child get the exact amount. In case you were wondering about the Viagra, we compound that. The hydralazine too.
As for penis + vagina = kid, when I worked in retail, I once had a retarded customer whose average IQ’d 8-year-old son was smarter than she was. She really did love her kids, but should never have had them.

Comment by denverpharm on 2009-03-22 19:46:21 -0700 #

I agree with the above comment. I see 400/5 more then the other two combined.

Comment by pharm tech on 2009-03-22 19:54:14 -0700 #

I know this isn’t what this rant is about, but we use a lot of 400/5 at our pharmacy too…I assumed the drug co sent out a very cool and colorful laminated sheet pointing out the fact that there is such a dose and that was the new rage because up until this past cold/flu season we never even carried it. Now our…um…PA (using the term loosly) writes it for every other patient who walks through her door. You always know which drug rep was in town or which drug sponsored seminar she went to. Chlorothiazide…anyone else EVER use this? According to her it is the newest and greatest drug ever yet she is the only one writing it…hmmmm!?! This is the same person who thinks that by her signing on the substitution permitted line we can dispense whatever drug we want…not brand/generic…we can’t get it through her head we can’t change someone from lipitor to simvastatin just because she signed on that line…Anyone else deal with these kind of dumbass prescription writers?

Comment by Shannon on 2009-03-22 20:11:11 -0700 #

LMAO I loved this rant and twatmuffin was great! I will be using this tomorrow when a retarded nurse calls the pharmacy!!! Thanks!!!

Comment by Doreen on 2009-03-22 21:59:34 -0700 #

Wow, this entry was timely.
Just have a father come in today demanding the pharmacy take responsibility for the fact his daughter has to go through another round of antibiotics. Why? Directions said 4mL. We were out of or couldn’t find 5mL syringes, so we gave him a 1mL syringe. What did he do? Give her 0.4 mL and, of course, it didn’t do anything for her. So it was our fault for not sitting him down and giving him a lesson in the metric system. If a grown man couldn’t work out that 4ml / 1ml = four syringes, then it’s hard to comprehend that more complicated directions are actually written.

Comment by East on 2009-03-23 00:19:28 -0700 #

Mmhmm- My vet takes a PPD syringe (or appropriate size) and DRAWS the correct dosage in red permanent marker for all patients. Perhaps that would work for some of your patients, track it in the notes? Sad that it needs to be done, but all I can say is- Children’s cold medicine….

Comment by on 2009-03-23 09:40:57 -0700 #

TAP for President.
I am so over these impossible dosages.
We don’t get very many of them here (thankfully) but when we do, you better believe the pharmacist on duty gets to call and give them a piece of their mind.

Comment by j on 2009-03-23 14:51:16 -0700 #

I had a hospital rotation where I had to check compliance on a set of rules for dosing. They P&T committee had to make a list of 20 drugs that come in variable mg/kg dosing and tell the doctors they could only prescribe in those set measured doses. If something came in 250mg/5cc then the prescriber could not write 215mg. This made me think of a few things.
5) Thank god someone had the brains to do this.
10) How sad, that someone had to think to do this.
15) Thank god people don’t have common sense, otherwise some of those pharmacists won’t have jobs.
20)We only had 85% compliance. Wait, pointing out common sense didn’t work?
25) We were 92% compliant when it came to suppositories. Yes, 500mg suppository and the script read 272mg. And before suppositories were on the list, this was very common. really?
30)We had doctors and nurses fighting us on this. Yelling and screaming like children who didn’t get ice cream yelling.

Comment by on 2009-03-23 15:57:36 -0700 #

I don’t experience this problem that often where I work, although the nurses never seem to figure out what strengths Augmentin comes in

Comment by Sumotoad on 2009-03-23 20:13:40 -0700 #

I was a chemist for 20 years before becoming a pharmacist, and a freaking good one too, and not even I can read a syringe to more than 1 decimal place. BTW, I recently had my wonderful, bright, capable and hottie pharmacist intern insulted by a dipshit doctor of osteopathy ( which is greek for “stupid asshole” if I remember correctly). She was told “That is why pharmacists should never have prescriptive authority” when she said the asthmatic patient on multiple, maxed-out asthma meds should be asked first of all, “Tell me how you use each of these medications….” to assess the shitbrain patient’s compliance before jumping in and changing a bunch of meds that the guy might not even be taking…. That has nothing to do with anything except that I hate DO’s even more than MD’s.

Comment by Paul S. on 2009-03-23 22:14:22 -0700 #

Yeah I just round it off for them. You forgot another big issue that really makes me upset.
Hey urgent care PA, next time you want to write a 21day supply of an antibiotic… DONT MAKE IT AUGMENTIN. Jeez, not only does the customer have to come back to get each new bottle mixed (and waste my time) but most of the time they leave the bottle out of the fridge for a couple hours (why does it go bad so fast?) and then they want me to replace it (and waste my time and money). Write for Septra Suspension so they dont have to make 3 trips to the pharmacy!

Comment by msawyedv on 2009-03-24 18:03:06 -0700 #

I love the rondec dm drops…actually had md write for 1/8 of 1/2 of dropper full…
we to go thru 400/5 like the lake nearby is made of it and we have to keep it full.
and lately some suprax…

Comment by FillMaster-5000 on 2009-03-25 02:23:45 -0700 #

We have this one PA who LOVES to write prescriptions with a Sig of “1&1/2 Tsp bid x7 days. Disp. QS”
Problem is “QS” equals 105 mL.
Pretty annoying, yes? We dispense 100 mL and replace “for 7 days” with “until gone”
BTW the generic Solodyn still cost about 480 bucks for 30 tabs of the 90mg. As opposed to 510 dollars for the brand. What a great Fuckin’ deal!!!
Meanwhile a bottle of fifty minocycline 100mg puts me back a whopping 6 dollars.

Comment by cassandra on 2009-03-25 19:58:48 -0700 #

How about this one…very common from a doc at my facility:
Albuterol concentrate solution
0.2 ml in 3 cc ns in nebulizer
Does he even look at the marks on the “sterile” dropper that comes with the albuterol soln? No…he has his nurse do the breathing treatments. What does he want me to do, give the patient a separate dropper to keep sterile and measure exactly 0.2 ml???

Comment by the misunderstood profession on 2009-03-26 12:51:11 -0700 #

Again, spot-on post. Epocrates being one of the worst PDA offenders available for lousy dosing (and no mech’s of action known for a majority of drugs, too! Go figure!) and the fools that take it at face value. What’s worse is the pharmacists that insult the rest of the thinking practitioners and verify these orders/send them out the door.
J–I would love to know what hospital boasts a P&T committee like that; that actually enforces common sense practices that benefit patients and doesn’t cave into every screaming MD/RN’s nonsensical whims. (“What do you MEAN I have to state my INR target before I enter a warfarin order?”)

Comment by Mike W. on 2009-03-27 12:51:17 -0700 #

Hey Shalom,
thanks for the heads up about the prevacid NDC. I hadn’t noticed that. I appreciate it.

Comment by techgirl on 2009-03-27 19:55:14 -0700 #

holy christ, YES.
we have this one prescriber in our area who ALWAYS writes for exact mg/kg dosing for every pediatric dose of any antibiotic (mostly azithromycin, oddly enough). i find it somewhat amusing though that if someone is over 18 but needs liquid dosing for whatever reason suddenly exact mg/kg is not so important and rounded figures are fine. every pharmacist i have ever worked with or spoken to in the area has tried to convince her that exact to four decimal place dosing is not necessary, but she remains unconvinced.

Comment by on 2009-04-01 09:47:56 -0700 #

I agree with most of what you said except the welfare mother that’s offensive. Most people regardless of how they pay for their medications (i.e. medicaid) don’t know how to use a dosing syringe. Marking the dose with a sharpie is probably a very obvious idea but I had never heard of it until now. I will be stealing that idea.

Comment by ミッシェル on 2009-04-15 23:19:49 -0700 #

Wow, thankfully our swarm of perscribers has been pretty good in this matter. Ours just like to click in the wrong drug.

Comment by JPH on 2009-05-10 16:40:19 -0700 #

Speaking of PDA crap, I had a NP try to call in a defunct Hydro/GG cough syrup prescription. I told her it wasn’t available anymore and she gets snippy and informs me her “latest” Nursing PDA software has it listed as a current med. I told her she got ripped off and was an idiot to boot.

Comment by doclori on 2009-08-19 22:00:31 -0700 #

As a pediatrician (and a mom) on a low-volume kick myself, it hadn’t occurred to me that my dosing system would contribute to mis-measurement by the patient — thanks for the insight.

Personally, I try to talk my patients into chewables or even “swallow-pills” (which you can get a cooperative 2 year old to learn to take, honest!), nothing to spill, mis-measure, or refrigerate.

Comment by Julie, angry NP on 2010-05-02 18:46:42 -0700 #

First I’d like to say that after browsing your site, that you have very good tips here for health care professionals.
I’ve also read the numerous inefficiencies you’ve noted in the system, and think it’s great that you are giving detailed suggestions for improvements.

However, in your frustration and *anger,* do try to remember that prescribers are also in a time crunch, that clinic wait lines are long, and that sick people are sent in and out in order to get to everyone. So as busy as you are, you’re not the only ones working through lunch hour to help patients. While NEW NPs, PAs, and even MDs may make the mistake of writing such craptastic orders like the ones you sited above, experienced NPs do not do this (Actually, we are taught not to do this in NP School!!!). Your blanket statements would be equivalent to me saying pharmacists never counsel patients and mindlessly disregard drug interactions by hitting the override key. Is it true? maybe for a few drug dealers, but not all. So there you have, it my angry rant back at ya.

I actually like pharmacists though, so don’t hate. We’re a team people!!

<3 Much love, Julie