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Medication safety: Management of the supply of unlicensed liquid medicines to children - recommendations for implementation

NHS England tasked the RCPCH/NPPG Medicines Committee to improve the safety of liquid medicines during the transition from hospital to home care. This follows several serious incidents, including the death of a child due to confusion over liquid morphine strengths.

Mistakes can occur because of the availability of multiple strengths of liquid medicines, particularly unlicensed ones (some medicines come in more than 10 different liquid strengths). The six recommendations listed here aim to prevent such incidents.

We also invite paediatricians and pharmacists to complete our quick questionnaire on discharge processes - link below.
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This resource, published in August 2024, was developed by the Royal College of Paediatrics and Child Health (RCPCH) and Neonatal and Paediatric Pharmacy Group Medicines Committee.

Six recommendations for implementation

  1. Define the formulary of common unlicensed liquid medicines. A formulary (official list) should be developed for commonly used unlicensed liquid medicines, with preferred or standardised concentrations. Some of this work has already started, but more needs to be done to include all necessary medicines, especially those used by adults.
  2. Standardise pharmacy labels for liquid medicines. Pharmacy labels for liquid medicines should be standardised to make them easier for parents and carers to understand. For example, labels should clearly show measurements in millilitres (mL) rather than just milligrams (mg). 
  3. Re-enforce the standardisation for medicines naming. Generic names of medicines should be used unless there is a specific reason to use a brand name. For instance, "liquid paracetamol" should be used instead of a brand name like "Calpol."
  4. Enforce the implementation of close monitoring of unlicensed liquid medicines following hospital discharge. Any unlicensed liquid medicines provided at hospital discharge should be closely monitored. The hospital pharmacy must communicate directly with the community pharmacy to ensure proper follow-up and continued supply. The Discharge Medicines Service in England is one example of how this can be done.
  5. Develop a nationally agreed transitional care prescribing framework (prescribing traffic light system). A national guide should be developed to standardise how unlicensed medicines are prescribed across different regions based on the 'RAG' (Red, Amber, Green) traffic light system. For example, all unlicensed medicines should be rated "AMBER" (meaning they require special consideration) in the prescribing system, and unlicensed morphine for children under 16 should be rated "RED" (meaning high caution). 
  6. Communicate the supply of medicines fully and clearly with parents and carers upon hospital discharge. Discharge letters should clearly state the RAG rating (Red, Amber or Green) of each medicine and provide detailed information on where parents can get more medicine if needed. This ensures everyone understands the child's medication needs and how to manage them safely. 

These recommendations are at varying stages of implementation. While some will take longer, the Medicines Committee is actively working to advance each one.

Your insights on discharge processes and medicines

We also want to assess the robustness of discharge processes for paediatric patients, focusing on the clarity and quality of information provided about medicines.

We have a short questionnaire for paediatricians, pharmacists, pharmacy technicians and other health professionals. Can you take five minutes to complete this? Your feedback will help us improve patient outcomes.