NCPDP Issues Patient Safety Guidance on Dosing of Oral Liquid Medications

Share Article

Calls for standardization of liquid dosing and labeling using mL and use of appropriate dosing devices to prevent harm from measurement errors and overdoses. Pediatric patients at particular risk as healthcare professionals often rely on liquid medications for treating young children.


National Council for Prescription Drug Programs

The PROTECT Initiative brought these issues to NCPDP based on its success in addressing and mobilizing the industry to take action on other patient safety issues.

NCPDP, the not-for-profit pharmacy standards development organization, announced today 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 which can lead to dispensing and later administration errors that can harm patients - especially pediatric patients who are often prescribed liquid medications.

“Adoption and implementation of the white paper recommendations will have an immediate impact on improving patient safety today,” explained 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 U.S. Food and Drug Administration (FDA) 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.

Overview of NCPDP Recommendations for Standardizing the Dosing Designation on Prescription Container Labels for Oral Liquid Medications:
1.    Milliliter (mL) should be the standard unit of measure used on prescription container labels for oral liquid medications.
2.    Dose amounts should always use leading zeros before the decimal point for amounts less than one (e.g., 0.5 mL) and should not use trailing zeros after a decimal point on prescription container labels for oral liquid medications (e.g., 5 mL).
3.    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.

Among the contributors to the NCPDP white paper (available in Appendix D) are representatives from Centers for Disease Control and Prevention (CDC), Institute for Safe Medication Practices (ISMP), FDA Safe Use Initiative, National Association of Boards of Pharmacy (NABP), American Society of Health-System Pharmacists (ASHP), retail pharmacies, healthcare vendors, consultants, health systems and others.

Dr. Daniel Budnitz, Director, Medication Safety Program, CDC, and leader of the PROTECT Initiative (Preventing Overdoses & Treatment Errors in Children Taskforce) explains that “this white paper supports a best practices approach to advancing children’s medication safety. The PROTECT Initiative brought these issues to NCPDP based on its success in addressing and mobilizing the industry to take action on other patient safety issues, and are looking forward to seeing this NCPDP white paper catalyze patient safety-oriented standardization industry-wide.”

Download the white paper at:

Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards Development Organization with over 1,600 members representing virtually every sector of the pharmacy services industry. Our diverse membership provides leadership and healthcare business solutions through education and standards, created using the consensus building process. NCPDP has been named in federal legislation, including HIPAA, MMA, and HITECH. NCPDP members have created standards such as the Telecommunication Standard and Batch Standard, the SCRIPT Standard for ePrescribing, the Manufacturers Rebate Standard and more to improve communication within the pharmacy industry. Our data products include dataQ®, a robust database of information on more than 76,000 pharmacies, and HCIdea®, an innovative prescriber database that provides continually updated information on more than two million prescribers. NCPDP's RxReconn® is a legislative tracking product for real-time monitoring of pharmacy-related state and national legislative and regulatory activity. For more information about NCPDP Standards, Data Services, Products, Educational Programs and Work Group meetings, go online at or call (480) 477-1000.


Share article on socal media or email:

View article via:

Pdf Print

Contact Author

Janet Cabibbo
+1 480-477-1000 Ext: 104
Email >

Maggie Bruce
480-477-1000 144
Email >
Visit website