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NP-005 Salt or base? Clear labelling of the reference value to prevent dosing errors: a case study

ejhpharm · 2026-03-18 · canonical JSON source

4 visible annotations · policy: published · automated confidence ≥ 75.00%

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Background The availability of medicinal products with different reference values in relation to the chemical form of an active ingredient used (as a salt or as a base) poses a risk of errors in dosing and manufacturing. Confusion between caffeine and caffeine citrate, for example, leads to a doubling of the dose. Awareness of this problem varies among those involved in the medication process, and information on the subject is often unclear.Objective In order to avoid dosing errors using medicinal products with different reference values, relevant monographs were identified in a web-based database for evidence-based drug information during childhood and information on the reference value was added.Methods The issue of reference values was discussed in round-table meetings involving an interprofessional group of experts consisting of pharmacists and paediatricians from university children’s hospitals and the Paediatrics Committee of the Federal Association of German Hospital Pharmacists (ADKA e.V.). Based on scientific evidence and clinical experience, criteria were established for selecting relevant monographs from the database, including the presence of different salt forms of an active ingredient. A revision process was developed to ensure that reference values are clearly labelled. Monographs with the above-mentioned risk constellation were revised.Results As of January 2025, 102 of the 671 monographs (15.2%) in the database were identified for which a reference value label is relevant. In these cases, the relevant reference values were labelled and their conversion factors were added to the ‘Formulations’ section of the database. In 80 monographs (11.9%), the reference value was also labelled at the dosage level (e.g. enalapril, sildenafil). The standardised revision of all monographs is ongoing.Summary The aim of this project is to increase vigilance for the risk of different reference values. Clear labelling in the database contributes to greater safety in prescribing and manufacturing.