NCPDP offers industry guidance on pediatric oral liquid medications

SCOTTSDALE, Ariz. — NCPDP, the not-for-profit pharmacy standards development organization, on Wednesday announced the availability of a patient safety white paper that provides specific industry guidance for standardizing the dosing designations and labeling of oral liquid medications. 

The white paper details patient risks associated with the variety of oral liquid dosing designations, prescribing practices and processing systems that can lead to dispensing, and later administration errors that can harm patients — especially pediatric patients who often are prescribed liquid medications.

“Adoption and implementation of the white paper recommendations will have an immediate impact on improving patient safety today,” said Lee Ann Stember, president of NCPDP. “This collaboration is another great example of what can be accomplished when NCPDP brings industry stakeholders together to address our most valued and vulnerable healthcare stakeholder — patients.”

NCPDP’s white paper provides best-practice guidance on prescription orders, prescription labeling and administration of oral liquid medications. The recommendations are consistent with best-practice requirements by The Joint Commission for certification across acute care inpatient settings, as well as Food and Drug Administration and industry recommendations for over-the-counter medicines. The white paper also covers the provision and use of appropriate dosing devices, as well as recommendations for caregiver and patient education to facilitate proper administration of oral liquid medications.

According to the recommendations, milliliter should be the standard unit of measure used on prescription container labels for oral liquid medications. Dose amounts should always use leading zeros before the decimal point for amounts less than one, and should not use trailing zeros after a decimal point on prescription container labels for oral liquid medications. And dosing devices with numeric graduations and units that correspond to the container labeling should be made easily and universally available, such as including a device each time oral liquid prescription medications are dispensed.

The white paper includes specific calls to action for industry stakeholders, but broadly calls organizations to communicate, adopt and implement the recommendations; measure organization performance and stress accountability across the organization for adhering to the recommendations; and develop patient-centered communications and encourage pharmacist-to-patient conversations at the point of dispensing. 

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