Fri 31 Jul 2015

Pharmacy Voice addresses ranitidine dispensing incidents

Pharmacy Voice claims introducing more robust procedures in community pharmacy could help to reduce the prevalence of dispensing incidents involving ranitidine liquid preparations. The recommendations are outlined in a Pharmacy Voice report released today detailing dispensing incidents involving ranitidine liquid for babies and children.


The report follows analysis of data from 6,796 pharmacies suggesting that around 60 dispensing incidents involving ranitidine liquid for children in England occur every year. The data revealed that around 40 of these incidents affect children under the age of two.

From these findings, Pharmacy Voice believes that further implementation of robust procedures in community pharmacy could help to reduce the prevalence of ranitidine incidents involving liquid preparations.

Janice Perkins, Pharmacy Voice board member and chair of the Patient Safety Group, says: “Dispensing incidents affecting babies and children are particularly traumatising for patients’ families, and for pharmacy staff. We hope that by providing some recommendations and effective shared learning for pharmacy teams, we will be able to reduce the occurrence of these unfortunate incidents.

“Whilst we may be looking at one particular medicine in this instance, Pharmacy Voice’s Patient Safety group has developed recommendations aiming to help reduce the occurrence of incidents involving all liquid preparations for babies and children. We are passionate about driving the patient safety agenda across the board, developing practical solutions to issues that impact us all in our working practice”

Pharmacy Voice met with the Medicines and Healthcare products Regulatory Agency (MHRA) and discussed the issues pharmacy teams can encounter with licensed and unlicensed preparations of ranitidine liquid. It was felt that there may be a need for greater communication between primary and secondary care when products are being prescribed for children.  Additionally, it was considered whether greater prominence could be given to the expression of strength on licensed preparations.

Following this meeting, Pharmacy Voice has compiled key recommendations for pharmacy teams into a one page Top Tips document on dispensing liquid preparations for babies and children.

Key recommendations include:

  • Check the date of birth on a prescription. If the prescription is for a patient under the age of 12, this should be highlighted by the branch colleague who receives the prescription;
  • any medication which has been prescribed outside the recommended age range should be discussed with the prescriber. The prescriber should also be reminded that this is an unlicensed indication, and carries additional liabilities and responsibilities for healthcare professionals involved;
  • considering the suitability of the prescribed medication for the individual child or infant, including the active and other ingredients;
  • calculations of dosage, taking into consideration body weight of patient;
  • clarification should be made to parents or carers on the exact volume in ml needed to give the intended dose in mg, especially if a dose is prescribed only in mg; and,
  • all pharmacies should ensure that small enough syringes are always in stock and supplied with the prescription to make measuring out prescribed doses easier for the parent or carer.

About ranitidine

Ranitidine is available on prescription for children under the age of sixteen for the short-term treatment of ulcers or to reduce the symptoms of indigestion and heartburn. For young children, especially those under two years of age, ranitidine will most often be prescribed as ranitidine hydrochloride in oral liquid form as an unlicensed preparation.

Notes to editors

The report, issued today, can be found in the new Pharmacy Voice Patient safety bulletin here.

Pharmacy Voice is an association of trade bodies which brings together and speaks on behalf of community pharmacy. Pharmacy Voice is formed by the three largest community pharmacy owner associations. Together we are a stronger, unified voice for community pharmacy.

For more information please contact Anouska Cope on / 020 8675 4779 / 07725 555030