News from NPPG September 2025

To bring attention to this critical issue, “Safe care for every newborn and every child” has been selected as the theme for World Patient Safety Day 2025, emphasising the need for stronger measures to protect children from preventable harm. Click the image above to go to the WHO site

Keeping Children Safe with Medicines – Everyone’s Responsibility

World Patient Safety Day 2025

By Chloe Benn, Consultant Paediatric Pharmacist, Vice Chair of the Neonatal and Paediatric Pharmacists Group (NPPG)

This year’s World Patient Safety Day theme, “Safe care for every newborn and every child”, reminds us that medicines safety is particularly important in children. Newborns and children are especially vulnerable to errors – their bodies handle medicines differently, doses are often weight-based, and many medicines are unlicensed or used off-label.

Safe and effective use of medicines in children requires specialist knowledge, standardised processes, and clear communication with families.

Why it matters

NPPG works closely with National organisations including the RCPCH to set shared priorities for safer children’s medicines:

• Improving the safety of unlicensed and off-label medicines
• Reducing medication errors through standardisation of products & processes
• Supporting safer transitions of care, such as hospital discharge
• Enhancing child-friendly formulations
• Involving children and families in decisions about their medicines

A real-life example

A young child with epilepsy was discharged on a liquid medicine at 5 mg/ml. The community pharmacy inadvertently supplied a 10 mg/ml strength. The family continued giving the same volume, effectively doubling the dose. The child became unwell and needed hospital admission.

Thankfully they recovered, but this illustrates the risks of variable liquid strengths. National work led by NPPG, RCPCH, and the BNF for Children is helping to prevent such incidents through standardisation of concentrationsand clearer labelling. Standardised strengths of liquid medicines for children – NPPG;  Standardised Infusions – NPPG

NPPG statement on standardised labelling

Medicines safety depends not only on the right medicine and dose, but also on the clarity of the information families receive. Confusing or inconsistent labels can increase the risk of error, especially where multiple strengths or formulations exist.

The NPPG statement on standardised labelling of oral medicines calls for:

1. For liquid medicines, the dose is expressed in millilitres (mL) only, (not both mg & ml & never mg only).
2. For solid dosage forms, the dose is expressed as the number of tablets or capsules to be taken, numericallyrather than in words, e.g. “1 capsule” not “one capsule”
3. The dosing frequency is expressed in words as the number of times “a day” the medicine should be taken, e.g.: “ONCE a day” or “FOUR times a day”.

Labelling of Dispensed Oral Medicines for Children position statement – NPPG

By aligning practice nationally, we can reduce misunderstandings and support both families and healthcare professionals to give medicines safely. Clearer labelling also supports wider safety initiatives such as standardised concentrations and improved discharge communication.

Supporting families

Parents and carers give most doses at home. They can help prevent harm by:

• Asking what the medicine is for, what strength, and how to give it
• Checking labels carefully, especially after discharge
• Using oral syringes & dedicated medicines measures rather than teaspoons
• Keeping a record of doses and side effects
• Using trusted resources like Medicines for Children (https://www.medicinesforchildren.org.uk/) or the My Child’s Meds app

Moving forward

Medicines save lives – but only when used safely. By reflecting, speaking up, and empowering families, we can create a safer system for every child.

On this World Patient Safety Day, let’s reaffirm our commitment: every child deserves medicines use that is effective, safe, and tailored to their needs.

Chloe Benn
Consultant Paediatric Pharmacist Barts Health
Vice Chair, Neonatal and Paediatric Pharmacists Group (NPPG)