Pharmaceutical Defence Limited (PDL) has issued an important alert urging pharmacists to exercise heightened care when handling prescriptions and over-the-counter requests for children. A recent annual review has revealed that children are involved in around 9 per cent of all incident reports received by PDL¹.

PDL Professional Officers point out that this figure may reflect a greater tendency to report incidents involving children, possibly because parents or carers are more likely to raise concerns, even if harm has not occurred¹. In fact, roughly 25 per cent of these reports involve a formal complaint, either to the pharmacy management or a regulatory authority².

The most common errors relate to incorrect dosage or labelling. A frequent scenario arises when a prescriber orders medication for a child in milligrams, but the dispensing software converts the value into millilitres. This can result in an unintended overdose if the medication is concentrated, particularly in liquid form. Examples include various antibiotic suspensions, prednisolone 5 mg/mL, atenolol 50 mg/10 mL, omeprazole and melatonin liquids².

PDL emphasises that children are “uniquely at risk” due to their distinct physiological traits, reliance on caregivers for communication, and increased sensitivity to dosing discrepancies. These factors demand a more tailored and vigilant approach from pharmacists².

This alert serves as a timely reminder that dispensing for paediatric patients requires additional checks. Verifying appropriate dosage units, clear and accurate labelling, and ensuring correct communication with caregivers are essential steps to safeguard patient safety. Pharmacists are encouraged to reflect on these risks and reinforce paediatric-specific procedures throughout their practice.