NCPDP Releases “Recommendations for Dose Accumulation Monitoring in the Inpatient Setting: Acetaminophen Case Model”

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New white paper identifies sources of unintentional acetaminophen overdosage, and opportunities to improve its safe use in the hospital setting, closing gaps to improve systems, communication, detection during transitions of care, and provider and patient education. Best practice recommendations may be applied to other drugs with narrow therapeutic ranges.


National Council for Prescription Drug Programs

NCPDP, the not-for-profit pharmacy standards development organization, announced today the availability of its new white paper, NCPDP Recommendations for Dose Accumulation Monitoring in the Inpatient Setting: Acetaminophen Case Model. This white paper is the latest in a series that provides patient safety guidance on a public health issue – accidental overdose of acetaminophen.

Studies have well documented the problem of supratherapeutic, or higher than therapeutically necessary, dosing for hospitalized patients, and the serious and potentially life-threatening risk of liver damage associated with overdose of acetaminophen. Overdose still occurs even with robust clinical decision support (CDS) tools and alerts to detect inappropriately-high ordered dosages and duplicate therapies. An American Society of Health-System Pharmacists (ASHP) 2013 national survey on informatics found that only about half of U.S. hospitals employing CDS-enabled CPOE systems actually calculate cumulative daily doses.

“Unintentional overdose in the inpatient setting is a patient safety issue that requires urgent attention,” explained David A. Kvancz, M.S., R.Ph., FASHP, Senior Vice President, Visante, Inc. and former senior health system executive and Chief Pharmacy Officer, most recently with Kaiser Permanente and The Cleveland Clinic.

Kvancz continued, “Each recommendation - from standardizing inpatient medication management protocols and optimally implementing medication safety technologies to establishing the pharmacist as the primary healthcare professional in the medication reconciliation process - can reduce patient risk of overdose. Implementation of the full set of recommendations will also bring consistency in best practices across both ambulatory and acute care settings.”

The recommendations contained in NCPDP’s white paper take a holistic view of systems, processes and people to identify opportunities for proactive intervention. The white paper includes best practices and guidance for reducing the risk of inadvertent acetaminophen overdosage during clinical handoffs such as between units or departments and care transitions such as from the inpatient to ambulatory care setting.

Summary of Recommendations and Stakeholders’ Call to Action for Dose Accumulation Monitoring for Medications Containing Acetaminophen
1. Minimize use of multiple-ingredient products containing acetaminophen.
2. Implement physician and nurse education with emphasis on maximum daily dose for medications at risk for overdose.
3. Provide patient education on medication use and the risk for overdose.
4. Establish standardized Inpatient Medication Management Protocols.
5. Establish pharmacists as the primary actor in the Medication Reconciliation Process.
6. Integrate health information technology solutions that minimize the risk of inadvertent overdosage for high-risk medications into all process flows and decision support.

“Recommendations in our previous white paper addressing unintentional overdose in the ambulatory setting were swiftly and widely adopted by industry,” explained Lee Ann Stember, President of NCPDP. “With this new white paper, our focus has shifted toward the acute care setting, providing guidance on closing the gaps during clinical handoffs and care transitions, and also providing appropriate patient and provider education to improve safe use of acetaminophen and avoid unintentional overdose.”

Download NCPDP Recommendations for Dose Accumulation Monitoring in the Inpatient Setting: Acetaminophen Case Model at: The white paper will also appear in the August 1, 2016 issue of the American Journal of Health-System Pharmacy (AJHP); Access the ahead-of-print version of the white paper at

Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards Development Organization with approximately 1,500 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.

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