The physician prescribed 4 drops of Lugol’s solution to be given orally every eight hours. 1 This event involved an adult patient with Graves’ disease who was admitted to the hospital with thyroid storm. Of the three errors reported to ISMP Canada, one was described in detail in the bulletin. Lugol’s solution is also approved for use as a topical antiseptic. Temporarily inhibits thyroid hormone synthesis and secretion-hence its use in treating thyrotoxic crisis and in reducing the risk of thyroid storm after thyroid surgery.īlocks thyroidal uptake of radioactive isotopes, thereby reducing the risk of thyroid cancer-hence its use in a radiation emergency or therapeutic/diagnostic exposure of radioactive iodine. Reduces thyroid vascularity-hence its use to reduce blood loss during thyroid surgery. Lugol’s solution contains 100 mg/mL of potassium iodide and 50 mg/mL of iodine. Another factor is that the product is used relatively infrequently and may be prescribed during an emergency, so unfamiliarity with the drug has been linked to many dosing errors. Thus, an adult dose expressed in drops is uncommon. One contributing factor may be that oral liquid medications for adults and young children are typically dosed in milliliters, while drops are typically reserved for infants. Most dosing errors involved prescribing, dispensing, or administering milliliter (mL) doses of Lugol’s solution when just a few drops were indicated. A quick search of the ISMP’s national Medication Errors Reporting Program (MERP) databases showed that a dozen oral dosing errors have been reported in the past six years. 1 The organization had received three reports involving incorrect oral dosing of Lugol’s solution. P roblem: A couple of years ago, ISMP (Institute for Safe Medication Practices) Canada published a safety bulletin on oral dosing errors associated with Lugol’s solution (potassium iodide and iodine), also referred to as strong iodine solution.