Quality Care

Harmonization of Dosing Designations for Oral Liquid Medications Across Acute & Ambulatory Care Settings


HIMSS/NCPDP Pharmacy Informatics Town Hall Series: Part 1 of 3

Unintentional overdoses and underdoses can happen when patients or caregivers administer oral liquid medications without an appropriate dosing instrument and clear, consistent dosing instructions on the medication container labels. This puts pediatric patients at particular risk as healthcare professionals often rely on liquid medications for treating young children. The U.S. Centers for Disease Control and Prevention’s (CDC’s) Prevention of Overdoses and Treatment Errors in Children Taskforce (PROTECT) Initiative, Institute for Safe Medication Practices (ISMP), FDA Safe Use Initiative, National Association of Boards of Pharmacy (NABP), American Society of Health‐System Pharmacists (ASHP), United States Pharmacopeial Convention (USP), American Academy of Pediatrics (AAP), retail pharmacies, healthcare vendors, consultants, health systems, and others have championed addressing this patient safety issue. The results of their efforts are industry guidance for harmonizing dosing designations across the acute and ambulatory care settings—consistent also with over-the-counter designations—and providing patients and caregivers with appropriate dosing instruments.

Attend this webinar, brought to you by National Council for Prescription Drug Programs, (NCPDP) and HIMSS, to learn about prescriber recommendations; manufacturing guidelines; and ePrescribing software certification standards. Plus, get details on new error-prevention research and lessons learned to continue to improve patient safety and patient health outcomes.

Learning Objectives

After attending this webinar, attendees will be able to:

  • Describe the safety rationale for using milliliter (mL) as the standard unit of measure used on prescription container labels for oral liquid medications.
  • Describe the safety rationale for why dose amounts should always use leading zeros before the decimal point for amounts less than one on prescription container labels for oral liquid medications.
  • Describe the safety rationale for why dose amounts should not use trailing zeros after a decimal point on prescription container labels for oral liquid medications.
  • Explain why dosing devices with numeric graduations and units that correspond to the container labeling should be made easily and universally available.
  • Explain why dosing devices should be of appropriate volume and accuracy for the amount prescribed.


  • Gerald McEvoy, PharmD., Consultant
  • Jennifer N. Lind, PharmD., MPH, MBA, Pharmacist Officer | Medication Safety Program, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC)
  • Shonna Yin, MD, Associate Professor of Pediatrics and Population Health, NYU School of Medicine

Sponsored content. The views and opinions expressed in this content or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

Sponsored by NCPDP.