Document resource
Aim Harm to children through inadvertent under/overdosing of liquid affects approximately 13% of prescriptions, often caused by liquid strength changes. 1 2 The National Health Service (NHS) incident reporting-system (Datix®) reported errors across prescribing boundaries (primary-secondary-tertiary-care) with propranolol and furosemide resulting in significant harm. The Paediatric Cardiac Specialist-Interest-Group (SIG) Neonatal Paediatric Pharmacy Group (NPPG) wanted to evaluate if there was a national approach for standardisation of liquid strengths for cardiac children and assess collaborative working across boundaries within Congenital-Heart-Disease-Networks (CHDN). Aiming to reduce changes to prescribing and dispensing of different strengths.Method National survey was developed and distributed to hospital pharmacists via the Cardiac SIG network, in February 2025, including questions on strengths of liquid formulations (captopril, propranolol, furosemide, spironolactone) prescribed/dispensed and CHDN communication methods.Results 17 responses from different hospitals were analysed: 59% level 1, 23% level 2 and 18% level 3, congenital cardiac centres. 100% encountered administration errors when liquid strengths change. Comparing hospital to hospital, 47% used the same strength for captopril, 59% for propranolol, 65% for furosemide, 94% for spironolactone. Various strengths of captopril, propranolol and furosemide were available because of shared drug-inventories with adult services, non-cardiac indications (e.g. propranolol for haemangioma) and administration issues. Spironolactone strength was consistent across the respondents, due to Royal College of Paediatrics and Child Health (RCPCH)/NPPG Position statement, 3 recommending one strength. There are no recommendations for the other licensed cardiac medicines. Communication of strengths on discharge from hospital; 88% to General Practitioner (G.P.), 18% to community pharmacist and unknown quantity from outpatient clinics to G.P. 12% of hospitals used the NHS Discharge Medication Service (DMS) providing information to community pharmacists. 18% had a CHDN strength policy adopted by Regional Area Prescribing Committees and District General Hospitals (DGH). However, 3 responses from linked DGH had no awareness of the policy within their CHDN.Conclusion Liquid medications for cardiac children are vital, complex and a cause of under/overdosing, causing harm. All respondents encountered these errors. The survey shows various strengths available within some hospitals and across CHDN due to shared inventory with adults, non-cardiac indications, administration issues and no position-statement. 3 The survey shows disparity (88% vs unknown) between communication of liquid strength to G.P.s at discharge versus clinics. Communication to community pharmacist (18%), including use of NHS DMS, was poor (12%). Potentially leading to primary care healthcare professionals (HCPs) having inadequate information from the initiating hospital, resulting in changes of liquid strengths, disrupting supply and harm.1 Liquid strength policies have been adopted by 3 out of 9 CHDN (England) across prescribing/dispensing boundaries, with the aim to improve the communication and expectation of the HCPs involved in the medication pathway,2 however from the survey there was a lack of awareness throughout the CHDN. The survey shows an inconsistent approach nationally to standardising liquid strengths of cardiac medicines across all prescribing/dispensing boundaries within the CHDN. The next steps include collaboration from the Cardiac SIG and CHDN; development of a national liquid strength policy, adopted by CHDN, and the advancement of the communication across prescribing/dispensing boundaries.References Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them [Internet]. The Pharmaceutical Journal. 2023. Available from: https://pharmaceutical-journal.com/article/ld/prescribing-errors-in-children-why-they-happen-and-how-to-prevent-them-2O’Hare A. Patient safety spotlight: the risks of prescribing and supplying medicines to children | General Pharmaceutical Council [Internet]. General Pharmaceutical Council. 2021. Available from: https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/patient-safety-spotlight-risks-prescribing-and-supplying-medicines-childrenNPPG Executive Committee. Using Standardised Concentrations of Liquid Medicines in Children [Internet]. 2025 Jun. Available from: https://nppg.org.uk/wp-content/uploads/2025/05/NPPG-Position-Statement-Standardised-Oral-Liquid-Concentrations-V11.pdf