A pint-sized (473 mL) container of concentrated acetaminophen drops may save time, money, and the environment, but also appears to raise the risk of medication errors.

Pediaphen, marketed by Brookstone Pharmaceuticals, comes in an 80 mg/0.8 mL concentration in the large bottle, which is aimed at hospital pharmacies. Print advertisements for the new concentrated drops compare Pediaphen with Tylenol concentrated acetaminophen drops, which come in 15-mL bottles. However, the larger container can lead to confusion between concentrated drops (80 mg/0.8 mL or 100 mg/mL) and children's acetaminophen liquid or elixir, which has a concentration of 160 mg/5 mL, or 32 mg/mL.

Acetaminophen concentrated drops from Tylenol and other companies are dispensed in smaller dropper bottles to encourage correct dosing. The smaller bottles also have cusps around the bottle opening that prevent the medicine from being poured into a cup. These features clue clinicians that the medicine is concentrated for small-volume dosing.

In contrast, the larger Pediaphen container has a screw cap, suggesting that the dose should be poured into a dosage cup (the proper dosing method for acetaminophen liquid or elixir). Also, the name Pediaphen may lead to name confusion with other children's products that begin with "pedia."

Brookstone Pharmaceuticals and the FDA have been alerted about the concerns with Pediaphen.