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Pharmacy Voice: Reduce ranitidine incidents among children

Pharmacy Voice wants pharmacists to clarify with parents the exact dose of a ranitidine solution in ml. Image: ParentingPatch

Around 60 dispensing errors involving the ulcer treatment and under-12s occur each year, according to an audit by the organisation

Pharmacy Voice has urged pharmacists to reduce dispensing errors involving ranitidine liquid preparations and children.

Around 60 children under the age of 12 receive the incorrect dosage of the liquid every year, suggested an audit by the organisation of data from almost 7,000 pharmacies in 2013 and 2014. Nearly two in three of these incidents affect children under two years old, it said in a report published today (July 31).

Although the figures equated to just one incident in every 2,700 prescriptions for the medication, Pharmacy Voice said there was “clearly still room for improvement”. It released guidance to boost safety when dispensing the product and called on pharmacy teams to implement these “robust procedures”, which include discussing the use of the medication outside the recommended age range with the prescriber. 

The guidance also urged pharmacists to clarify with parents or carers the exact dose of the solution in ml, and to make sure to consider the body weight of the patient when calculating the dosage.

Pharmacy Voice warned that "errors can be made" in calculations that result in patient safety incidents.

“Although ranitidine is very specific in action and no particular problems are expected following an overdose, pharmacy teams strive to reduce the likelihood of any patient safety incidents, especially those affecting young children,” it said.

Other measures

Pharmacy Voice conducted the audit because “a number” of its medication safety officers had “detected reoccurring incidents” with ranitidine liquid preparations, it said. 

But the organisation suggested it was not just down to pharmacy teams to rectify the problem. It had already met with the Medicines and Healthcare products Regulatory Authority (MHRA) to discuss whether “greater prominence” could be given to the strength on licensed packs of ranitidine liquid preparations, it said.

At the meeting, both organisations also felt “there may be a need for greater communication between primary and secondary care when products are being prescribed for children”, Pharmacy Voice added.

Pharmacy Voice board member Janice Perkins said dispensing incidents involving children are “particularly traumatising” and the organisation hopes its recommendations will reduce these “unfortunate” events.


Have you ever made a dispensing error involving a child?

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Mohammed Rafiq, Community pharmacist

Also short expiry date to consider once opened especially with 300ml bottle; 1 month once opened with most brands.

Pharmacy HLP, Manager

It may seem a cop out but in most cases the patients parents knows more than their GPs and it is almost impossible to get to the primary practitioner to establish dose or any other matter. In the absence of this information path a robust dose / weight chart would be extremely helpful. Then the problem become further complicated by off licence and unlicensed use, in community we are familiar with ranitidine username children but in many cases not confident to challenge what is prescribed. In the extra complication is misunderstanding the dose as in many cases a 300 ml bottle is dispensed but the child may only be taking a fraction of a ml as a dose so this can lead to confusion and errors even when trying to follow prescribed information.

Pillman Uk, Non Pharmacist Branch Manager

I notice that ranitidine preparations are cited in the article, but surpsingly nothing about the ethanol content of some ranitidine preparations. I'm sure during an NPA webinar on dispesning errors, the ethanol was highlighted as a signifcant issue in one dispensing error reported.

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