How to calculate drug dosage

accurately: advice for nurses

1 September, 2002
The lack of basic maths skills can be a major problem when it comes to nurses
administering drugs to patients. Calculations are still a significant source of drug error.
Steve Haigh.
Senior Pharmacist, Medicines Information and Formulary, Sherwood Forest Hospitals
The lack of basic maths skills can be a major problem when it comes to nurses administering drugs to
patients. Calculations are still a significant source of drug error.

Parenteral opiates are often relied on to manage acute pain in patients needing effective analgesia.
But errors resulting in overdose of intravenous opiate can lead rapidly to respiratory depression. The
opiate antagonist naloxone reverses opiate overdose and is usually needed quickly. However, this can
cause confusion, because the product is prepared in micrograms. A small volume is involved, and the
dose given needs to be titrated against response.

Postoperatively, the epidural route is now common for infusions of opiate and local
anaesthetic. If opiates or, indeed, most drugs, have been calculated incorrectly, the
consequences for patients can be serious.

If given in too high concentrations, local anaesthetic used in epidural infusions can cause
extensive motor blockade, leading to immobility and pressure ulcers, which is distressing to
the patient (Lee, 1991). Wheatley et al (2001) call for routine use of pre-filled epidural
infusion bags to avoid the risk of calculation error when ward staff prepare infusions.

Nursing competence in drug calculations has been a cause for concern (Duffin, 2000;
Coombes, 2000). Hutton (1998a) suggests that a degree of de-skilling has resulted from
the increasingly user-friendliness of drug preparations and widespread use of electronic drip
counters.

Her research into students competence in drug calculations demonstrated a marked
improvement on initial test results after a structured revision programme.

Written accounts obtained from students in the study revealed that many felt unable to
perform calculations such as long division and fractions without using a calculator, as they
had come to rely on these at school.

There is some debate over calculator use. Hutton (1998b) argues that calculators are
usually available in areas where calculations are complex, and that their use should be
encouraged.

The opinion of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting
(UKCC) (now the Nursing and Midwifery Council) is that nurses should not rely too heavily
on calculators.

The latest guidelines for the administration of medicines (UKCC, 2000) state that the use of
calculators should not act as a substitute for arithmetical knowledge and skill.

Developing calculation skills relies on understanding decimals to make conversion easier.
And when using long division it is essential to get it the right way round. The use of simple,
memorable formulae for regular reference can be a great help (Box 1).

Drug calculations
Drug calculations appear to be impossibly difficult, unless you break them down into small
steps. They are vitally important to get right, yet they are so easy to get wrong. This paper
will now look at some commonly used drug calculations and the way that mistakes can
happen.

Type A calculations
When the dose you want is not a whole ampoule.

For example:

- Prescription states 200mg (milligrams)
- You have an ampoule of 500mg (milligrams) in 4ml (millilitres).
What volume contains the dose you need?

If you have an ampoule of 500mg in 4ml, and you need 200mg, it can appear to be a
daunting calculation. The first step is to find out what volume contains 1mg (4/500) and
then multiply it by how many mg you want (200).

The easy way to remember this is the famous nursing equation:

What you want, over what youve got, times what its in

In this instance:

200mg x 4ml / 500mg = 1.6ml

The common error here is to get it upside down, and divide what youve got by what you
want. This fortunately gives you a stupid answer, which is obviously wrong, in this case
10ml. You already know that you need a fraction of an ampoule and not two and a bit
ampoules, which highlights the error.

To help make sure you get it the right way up, remember WIG:

What you Want x what its In / What youve Got

Converting units
All weights, volumes and times in any equation must be in the same units. With weights the
unit changes every thousand. For example, you need 1000 micrograms (mcg) to make 1
milligram (mg) and 1000 milligrams to make one gram (g) (Box 2).

Type B calculations
These are infusion rate calculations.

For example:
- Prescription states 30 mg/hour
- You have a bag containing 250mg in 50ml
Therefore, at what rate (ml/hr) do you set the pump?

These are the same as type A calculations, only once you have worked out the volume that
contains the amount of drug you need, you set the pump to give that amount per hour.

In this instance, work out how many ml contain ONE mg of drug

Using the WIG equation

30 x 50 / 250 = 6ml

Therefore the calculation shows that, to give 30mg per hour, the infusion pump rate would
need to be set at 6ml per hour.

This calculation is straightforward when the rate you want (30mg/hour) and the amount of
the drug in the bag (250mg) are both in the same units (mg).

However, if the infusion required that 600 micrograms were to be infused each hour
instead, this would first need to be converted into mg before the infusion rate was
calculated, that is, 600 micrograms = 0.6mg.

The equation for infusion rate calculation is dose stated in prescription (milligrams per hour)
times volume in syringe (in millilitres) divided by the amount in the syringe (in milligrams)
equals the infusion rate (millilitres per hour), or:

Dose (mg/hr) x volume in syringe (ml) / Amount in syringe (mg) = Infusion rate

Type C calculations
Infusion rate is required, but dose is mg per kg.

For example:

- Prescription states 0.5mg/kg/hour
- You have a bag of 250mg in 50ml
- Your patient weighs 70kg.
At what rate (ml/hr) do you set the pump?

To do this calculation you still use the WIG equation as above, but with one extra step to
work out the what you want.

First you need to convert the mg per kg into total mg by multiplying it by the patients
weight.

So for a person who weighs 70kg, 0.5mg per kg is the same as 35mg. Once you have
calculated this, the infusion rate can be worked out as in the Type B calculations.

In this instance:

0.5mg/kg/hr x 70kg x 50ml / 250mg = 7ml/hr

Type D calculations
Infusion rate required, but dose is in mg/kg/min.

For example:
- Prescription states 0.5mg/kg/min
- You have a syringe of 250mg in 50ml
- Your patient weighs 70kg



At what rate (ml/hr) do you set the pump?



As before, you will need to calculate what you want by multiplying the amount per kg by the
patients weight. In this case:



0.5mg x 70kg = 35mg



This time, however, the prescription states the rate per minute. The pump demands that
the rate be set in ml per hour, therefore the rate per minute will need to be converted
before the equation can be completed, by multiplying 35 by 60; that is, 35mg/min (35
milligrams per minute) is converted to 2100mg/hr (2100 milligrams per hour).



From here, once again we use the type B calculation to find the infusion rate, which as
shown will be 420ml/hr.



2100 x 50 / 250mg = 420ml/hr



Type E calculations



Infusion rate is required, but the dose is in mcg/kg/min. For example:

- Prescription states 3 micrograms (mcg)/kg/min

- You have a syringe of 100mg in 50ml

- Your patient weighs 70kg.

At what rate do you set the pump (ml/hr)?


As before, what you want is calculated by multiplying the amount per kg by the patients
weight, that is:

3mcg/kg for a 70kg person is 210mcg.

Next the prescription rate needs to be converted into rate per hour, that is,

210mcg/min = 12 600mcg/hr



The prescription is in micrograms, but in your syringe you have milligrams. Both need to be
in the same units, so you must convert one to the other, in this case mcg to mg. 12
600mcg/hr is the same as 12.6mg/hr.
The calculation is then as follows:

12.6 x 50 / 100 = 6.3ml/hr

Conclusion
A UKCC council meeting in Belfast in June 2000 expressed concern at the lack of basic
maths skills (Coombes, 2000; Duffin, 2000) among nurses.

The risk of error was felt to be unacceptably high, especially in paediatric nursing, where the
necessity for calculating dosages according to body weight increases calculation complexity.

The GCSE Mathematics pass at Grade C or above, or equivalent, a compulsory entry
requirement for nurse training, was not felt to be adequate preparation for nursing training,
and Hutton (1998a) agrees with this.

An anonymous author described personal experience of a drug error (Anon, 2000) and how
it almost cost her loss of registration. She was lucky enough to have managers who offered
her support, and helped with her realisation of the need for urgent basic maths revision.

Open reporting systems and no blame cultures are recommended by the UKCC (2000) and
are helpful in changing ways of working (Alderman, 1997). Reported learning initiatives
(Coombes, 2000; Wilson, 2000) are welcome indications of a growing number of practical
solutions.

Test exercises: try these out for yourself (answers below)
Question 1

Prescription for IV ampicillin 200mg

- You have a vial of 500mg in 10ml
- What volume contains the dose you need?
Question 2
Prescription for IV digoxin 187.5mcg
- You have a vial of 0.5mg in 2ml
- What volume contains the dose you need?

Question 3
Prescription for IV aminophylline 350mg in 100ml to be given over 30 mins
- You have some vials, 250mg in 5ml
- What volume of aminophylline injection do you add to the bag?
- What rate do you set the pump at (ml/hour)?
Question 4
Prescription for dopamine 2mg /kg/hour
- You have a 70kg patient and a syringe of 800mg in 50ml
- What rate do you run the syringe at (ml/hour)?
Question 5
Prescription for IV doxapram 0.1mg/kg/minute
- You have a 90kg patient and a bag of 500mg in 250ml
- What rate do you run the syringe at (ml/hour)?
Question 6


Prescription for IV noradrenaline 10microgram/kg/minute

- You have a 60kg patient and a syringe of 16mg in 50ml
- What rate do you run the syringe at (ml/hour)?

Question 7
You need to give 500mg of dextrose
- You have a 250ml bag of 5% dextrose
- How many ml do you need to give?

Question 8
You need to give 5ml of 0.375% bupivacaine
- You have a 10ml ampoule of 0.5% bupivacaine and some water for injections
Answer 1

WIG: 200mg x 10ml / 500mg = 4ml

Answer 2

0.5mg = 500mcg
WIG: 187.5mcg x 2ml / 500mcg = 0.75ml

Answer 3

WIG: 350mg x 5ml / 250mg = 7ml

60 min x 100ml / 30 min = 200ml/hour

NB When you need ml/hour the equation is:

60 x ml to infuse / Duration of infusion

Answer 4

Prescription really says

2mg/kg/hour

2mg x 70kg = 140mg/hour needed

WIG: 140mg x 50ml / 800mg = 8.75ml


So 8.75ml per hour

Answer 5

Prescription really says: 0.1mg/kg/minute

0.1mg x 90kg = 9mg/minute

9mg/minute = 9 x 60mg/hour = 540mg/hour

WIG: 540mg x 250ml / 500mg = 270ml
So 270ml per hour

Answer 6

Prescription really says: 10mcg/kg/min

10mcg x 60kg = 600mcg/min

600mcg x 60 min = 36000mcg/hr

36000 / 1000 = 36mg/hr

WIG: 36mg x 50ml / 16mg = 112.5ml

So 112.5ml per hour


Answer 7

5% means 5g in 100ml
which is the same as 5000mg in 100ml

WIG: 500mg x 100ml / 5000mg = 10ml
Answer 8

We need 5ml of 0.375% solution. This would contain 0.375g in 100ml. So in 5ml there
would be 0.375g x 5ml / 100ml = 0.01875g (18.75mg) (line 1)

We have a 0.5% solution (which contains 0.5g (500mg) in 100ml)

We need 18.75mg.

WIG 18.75mg x 100 / 500 = 3.75ml

So the 18.75mg we need is contained in 3.75ml of our 0.5% solution
So we take 3.75ml (18.75mg), top it up to 5ml with WFI, and we then have 18.75mg in
5ml (which is 0.375% as shown in line 1)