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SP3 An exploratory study to characterise dosing instructions on dispensed paediatric medicines labels
  1. Faiza Latheef1,
  2. Asia Rashed1,
  3. Andrew Wignell2,
  4. Stephen Tomlin3,
  5. Mandy Wan1
  1. 1Evelina London Children’s Hospital
  2. 2Nottingham University Hospitals NHS Trust
  3. 3Great Ormond Street Hospital, London


Aim The dispensing label is the primary means by which healthcare professionals communicate dosing instructions on how and when to administer a medicine to patients. Yet, the misreading or misinterpreting of dosing instructions is frequently cited as a contributing factor in cases of unintended dosing errors, where such instructions are frequently more complex in paediatrics.1 2 Variations in how these instructions are presented creates another potential source of confusion. This study aims to comprehensively characterise and compare the content and wording of dosing instructions used by pharmacy professionals when labelling medicines dispensed to children in UK hospital settings.

Method A web-based anonymous survey was distributed via the Neonatal and Paediatric Pharmacists Group (450 pharmacy members across the UK) in October 2022 over a 4-week period. The participant’s job role and their amount of pharmacy and paediatric experience were collected. The survey presented a series of 8 paediatric prescriptions chosen for their diversity of administration: amoxicillin oral suspension, azithromycin oral suspension, propranolol liquid, aspirin dispersible tablets, chlorphenamine liquid, Movicol® sachets, glycopyrronium bromide oral solution and tacrolimus capsules. Participants were asked to provide the wording of dosing instructions that they would use on the dispensing label in routine practice. Descriptive statistical analysis was conducted using R Statistical Software, (v4.1.2; R Core Team 2021).

Results A total of 926 dosing instructions were analysed from 121 participants across 55 hospitals. Of the 805 dosing instructions for children under 12 years of age, the use of active voice was most frequent at 69.4% for ‘give’, while 28.2% used ‘take’ and 1.7% used the passive voice. Of the 121 dosing instructions for children over 12 years of age, the use of active voice was most frequent at 58.7% for ‘take’, while 38% used ‘give’ and 2.5% used the passive voice. For dosing instructions involving solid dosage forms or sachets (n=240), 86.7% expressed the dose amount in words (eg one capsule), rather than numerals (e.g., 1 capsule). Of the 686 dosing instructions involving medicines administered in liquid form, 65.7% expressed the dose amount in terms of ‘ml’, 30.1% as ‘ml (mg)’, and 4.3% expressed as ‘mg’, ‘mg (ml)’, or ‘ml (ml)’ (e.g., 2 mL (two ml)). Volumetric measures were also expressed using words and numerals (eg. ‘One 6.25 ml dose’). The amount of water recommended for dispersing one 75 mg aspirin tablet to facilitate fractional dosing ranged from 3 ml to 75 ml. For each of the 8 prescriptions, dosing instructions were worded on an average of 90 different ways (range: 80–120).

Conclusion This study shows the wide range of approaches used by pharmacy professionals to communicate paediatric dosing instructions on dispensing label. The inconsistency in how volumetric measures are expressed is concerning. Our findings indicate that our current practice deviates from general recommendations on how to communicate healthcare information. Standardising the presentation of dosing instructions on dispensing label has the potential to improve user comprehension. However, to support the development of evidence-based standards, more research, including user testing, is required.


  1. Bailey SC, Pandit AU, Yin S, et al. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med 2009;41:715–21.

  2. Robinson J, McKenzie C, MacLeod D. Paediatric dosing errors with oral prednisolone mixture. Aust Prescr 2016;39:176.

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