Preventing Home Medication Administration Errors

Medication errors at home in the pediatric population: An assessment from a parent's perspective

PURPOSE

The aim of this study is to examine the frequency of medication errors made by parents while administering medication to their children at home, and explore the relationship and associated variables with these errors.

MATERIALS AND METHOD

The study utilized a screening model to explore medication administration patterns among parents of children aged 0-12 years in Türkiye. Data were collected through an online survey using a snowball method, with 730 parents participating. Information was gathered using a General Information Form and a Survey Form, and the responses were analyzed using SPSS and RStudio. Chi-square tests and multiple regression analyses were performed to assess relationships between variables and medication errors. Data collection occurred between July 2022 and July 2023.

RESULTS

The study found a 15.9 % rate of medication errors among parents administering medication to their children. The analysis of medication errors revealed that missed drug doses were the most frequent error, accounting for 60.3 % of cases. This was followed by the administration of lower drug doses (19.8 %), non-adherence to storage instructions (8.6 %), administration of excessively higher drug doses (7.8 %), and misuse of medications (3.4 %). Chi-square tests revealed significant relationships between medication errors and various factors, such as challenges during administration, support received, and the use of telephone consultations. Multiple regression analysis identified difficulty in administering medication and the use of telephone consultations as factors significantly associated with medication error.

CONCLUSION

The results highlight the need for increased support and education for parents to reduce errors during medication administration.

Unraveling tenfold administration errors of oral risperidone solution in children

INTRODUCTION

In early 2023, the Israeli National Poison Information Center received reports of children exposed to tenfold dosing errors of oral risperidone solution. To assess the scope of this issue, we systematically searched for all similar cases reported to the Israeli National Poison Information Center. Our aims were to describe the occurrence and causes of such errors and explore potential preventive measures.

METHODS

Using the Israeli National Poison Information Center database, we retrospectively identified and reviewed cases of unintentional tenfold oral risperidone solution overdoses in children under 13 years of age between 1 January 2020, and 31 December 2023. We collected information about demographics, the circumstances of the administration error, and patient disposition and outcomes.

RESULTS

We identified 60 children (median age 7 years; IQR: 5.5-9 years; 73% boys) who were exposed to a tenfold error in the administration of oral risperidone solution. In 48% of cases, the error occurred upon the first administration. The main contributing factor to this dosing error appeared to be the discrepancy between the small dosing volume of the doses prescribed (approximately 0.25 mL) and the comparatively large syringe size provided by the manufacturer in the package (3 mL). We reported this issue to the Israeli Ministry of Health, which published a safety alert warning health care professional about such administration errors.

DISCUSSION

Oral medication solutions need to be measured individually and are therefore associated with a higher likelihood of dosing errors compared to tablets.

CONCLUSION

Health care workers and caregivers need to be aware of the risk of dosing errors when administrating oral risperidone solution to children. Supplying appropriate dosing syringes with the medication bottle may mitigate the risks of such administration errors.

Disclosure of Adverse Events in Pediatrics: Policy Statement

Disclosure of adverse events has become the expectation in medicine and is widely regarded as the appropriate path when medical errors occur. Although data are limited on adverse events in pediatrics, that they occur frequently is uncontested. Types and rates of errors vary depending on the care setting and patient population. Patients with complex medical conditions or from historically marginalized groups or minoritized communities likely suffer disparate health and safety outcomes. Systemic factors, including nonpunitive safety cultures and supportive environments within institutions, are essential to promoting disclosure. State laws protecting apologies from use in legal proceedings can also help to encourage open communication. Some states have adopted laws to advance disclosure, and governmental agencies provide materials encouraging open communication and early resolution after adverse events occur. Many programs emphasize the importance of supporting health care workers involved in adverse events. Shame, fear of professional and legal repercussions, and lack of training remain barriers to disclosure. Education for health care clinicians, support in health care settings, additional research on programs and disparities, and governmental and regulatory initiatives can support disclosure of adverse events.

A Training for Parents Prevents Clinically Relevant Handling Errors in the Use of Long-Term Antiseizure Medication

BACKGROUND

Medication handling errors (ME) in long-term antiseizure medication (ASM) compromise patient safety. Training programs to prevent those errors by parents are scarce.

PATIENTS

The intervention concept is designed for parents of children and adolescents aged 0-18 years with at least one long-term ASM.

METHOD

In a controlled prospective study, we assessed ME of ASM during home visits 3-6 weeks after a patient's in- or outpatient hospital visit (outpatient neuropediatric clinic and Social-Pediatric Center (SPZ)). We investigated the effectiveness of a patient specific, risk-adapted training (intervention group, IG) compared to routine care (control group, CG). For 54 ME in ASM handling, an expert panel classified the clinical risk ranging from Score-0 (no risk) to Score-6 (maximum risk) with the lowest risk actually classified as Score-3.

RESULTS

We analyzed data from 83 parents in the CG and 85 in the IG who administered 140 ASM per group. The intervention reduced ME per patient from 5 (median; Q25/Q75 3/9) to 4 (2/8; p=0.018). A total number of 589 ME occurred in the CG, 432 in the IG. ME in ASM handling rated Score-6 occurred once in the CG and not in the IG. A relative-risk-reduction (RRR) of ME (with p<0.001) was observed, with a RRR of 55.0% for Score-5, 27.6% for Score-4, and 23.1% for Score-3. RRR was 56.6% for ASM preparation (p<0.001) and 22.4% for oral administration (p=0.045).

CONCLUSION

Compared to controls, ME with high clinical risk significantly decreased in the IG after the training. Drug safety in chronically ill children with ASM was thereby improved.

Improving Timely Administration of Essential Outpatient Medications in a Pediatric ED

BACKGROUND AND OBJECTIVES

The complexity of pediatric patients' outpatient medication regimens is increasing, and risk for medication errors is compounded in a busy emergency department (ED). As ED length of stay (LOS) increases, timely and accurate administration of essential outpatient medications has become increasingly challenging. Our objective was to increase the frequency of ordering of essential outpatient medications for patients with ED LOS >4 hours from 56% to 80% by June 2023.

METHODS

We conducted a quality improvement (QI) initiative in a pediatric ED with ∼60 000 annual visits comprising a total of 91 000 annual medication orders. We defined essential outpatient medications as antiepileptic drugs, cardiovascular medications, and immunosuppressants. Our QI interventions included a combination of electronic health record interventions, a triage notification system to identify patients with essential outpatient medications, and widespread educational interventions including trainee orientation and individualized nursing education. The primary outcome measure was percentage of essential outpatient medications ordered among patients with an ED LOS >4 hours, with a secondary measure of outpatient medication safety events.

RESULTS

Baseline monthly ordering rate of selected medications for patients with an ED LOS >4 hours was 54%, with an increase to 66% over the study period. Refining our population yielded a rate of 81%. Outpatient medication safety events remained unchanged, with an average of 952 ED encounters between events.

CONCLUSIONS

A multidisciplinary QI initiative led to increased essential outpatient medication ordering for patients in a pediatric ED with no change in safety events.

The Challenges for EU User Testing Policies for Patient Information Leaflets

Patient information leaflets (PILs) are essential tools in healthcare, providing crucial information about medication use. In the European Union, the European Medicines Agency (EMA) oversees the regulation and standardisation of PILs to ensure their readability and accessibility. However, challenges persist in ensuring these documents are comprehensible and user-friendly. This study employs a qualitative analytical approach, reviewing existing literature and regulatory documents to identify gaps in the EU user testing policies for PILs. It focuses on the diversity of participant samples, the independence of the testing process, and the robustness of user testing protocols. Findings indicate that current user testing practices often lack diversity and may be biased when pharmaceutical companies conduct their own tests. Additionally, there is a lack of user testing protocols for translated PILs, potentially compromising their accuracy and cultural relevance. To improve the efficacy of PILs, it is essential to include diverse and representative samples in user testing, mandate independent third-party evaluations, implement protocols for user testing on translated PILs, and ensure continuous updates to guidelines based on the latest best practices in health communication. These measures will enhance patient safety and understanding of medication information.

Mind the Decimal Point: A Case of Diazoxide Overdose-Induced Ileus

Diazoxide is the only medication approved by the United States Food and Drug Administration for the treatment of hyperinsulinism-induced hypoglycemia. Overdose is infrequently reported. This case describes a preterm four-week-old male who was prescribed diazoxide and chlorothiazide for perinatal stress-induced hyperinsulinism. The patient presented to the emergency department with feeding intolerance and abdominal distension following an accidental 10-fold diazoxide overdose. On presentation, vital signs were remarkable for tachycardia and intermittent tachypnea. Physical exam revealed a grossly distended abdomen. Laboratory abnormalities included a glucose of 216 mg/dL, sodium of 132 mmol/L, and chloride of 98 mmol/L. Abdominal X-ray interpretation found moderate gaseous distension suggestive of generalized ileus. The patient was admitted to the neonatal intensive care unit (NICU), and a nasogastric tube was placed. He received intravenous dextrose fluids, and enteral feeds were resumed as serial X-rays showed interval improvement. The patient remained in the NICU for several days to monitor bowel movements and resolution of ileus and he was discharged after improvement. While diazoxide overdose is rarely reported, and ileus due to such is documented even less frequently, 10-fold medication dose errors are common among infants. The source of the 10-fold mistake is often decimal points, leading zeros, or trailing zeros. Utilizing the smallest possible syringe for the prescribed dose may reduce the incidence of medication errors.

Measurement of Polyethylene Glycol 3350 With Standard Household Measuring Devices

OBJECTIVE

Though standard household measuring devices (e.g., teaspoons, tablespoons) are often used in clinical practice to measure pediatric doses of polyethylene glycol 3350 (PEG-3350), no published -literature documents the accuracy of these measurements. Standard dosing for adults is 17 grams, which is 1 capful according to the manufacturer. The objective of this study was to determine the weight of household teaspoons and tablespoons of PEG-3350.

METHODS

PEG-3350 measurements were performed using 5 different household measuring teaspoons and tablespoons and the cap that accompanies the bottle for 3 different brands of PEG-3350. Using an electronic balance to determine weights, 3 investigators completed 5 measurements for each of the 5 measurement devices and PEG-3350 bottle caps as follows: leveled teaspoons and tablespoons, unleveled teaspoons and tablespoons, "heaping" tablespoons, half-capfuls, and capfuls.

RESULTS

A leveled teaspoonful of PEG-3350 weighed ∼3.3 grams and an unleveled teaspoonful weighed ∼3.7 grams. A leveled, unleveled, and heaping tablespoon of PEG-3350 weighed about 10, 11, and 15 grams, respectively. Heaping tablespoons, half-capfuls, and capfuls resulted in the most measurement variability.

CONCLUSIONS

Use of a kitchen scale may be the most precise method of measurement, however not all patients have kitchen scales. Standard household measuring devices (teaspoons and tablespoons) may be used to conveniently measure PEG-3350 doses. Using 1 dedicated measurement device and leveling the dose may improve consistency, which could be beneficial for patients who are sensitive to dose variability.

Changes in Provider Perceptions and Practices Regarding Dosing Units for Oral Liquid Medications

OBJECTIVE

A 2015 survey of primary care providers (PCPs) found that while many believed that milliliter (mL)-only dosing was safest for oral liquid medications, few would use mL alone in dosing instructions. Since 2015, many recommendations have promoted "mL-only" dosing. In 2019, a follow-up survey was conducted to assess if PCP perceptions and practices have changed.

METHODS

Pediatricians, family medicine physicians, nurse practitioners, and internists participating in the 2015 and 2019 DocStyles cross-sectional, web-based surveys were asked about their perceptions and practices regarding dosing units for oral liquid medications.

RESULTS

In 2019, among 1392 respondents, the proportion of PCPs who reported they believed using mL-only is the safest dosing instruction ranged from 55.1% of internists to 80.8% of pediatricians. While fewer PCPs believed patients/caregivers prefer dosing instructions in mL-only (23.9% of nurse practitioners to 48.4% of pediatricians), more held this belief in 2019 compared to 2015; pediatricians had the greatest absolute increase (+14.4%) and family medicine physicians had the smallest increase (+1.3%). While 61.6% of pediatricians reported they would use mL-only dosing, only 36.0% of internists, 36.6% of nurse practitioners, and 42.5% of family medicine physicians reported they would do so. After controlling for age, gender, region, and specialty, 2019 PCP survey participants were more likely to report that they would use mL-only dosing compared to 2015 participants (adjusted odds ratio 1.51, 95% confidence interval 1.29-1.77).

CONCLUSIONS

Broader educational efforts may be necessary to reach nonpediatricians, to encourage prescribing and communication with patients/caregivers using mL-only dosing.

Prevalence of medication errors and its related factors in Iranian nurses: an updated systematic review and meta-analysis

BACKGROUND

Nurses may make medication errors during the implementation of therapeutic interventions, which initially threaten the patient's health and safety and prolong their hospital stay. These errors have always been a challenge for healthcare systems. Given that factors such as the timing, type, and causes of medication errors can serve as suitable predictors for their occurrence, we have decided to conduct a review study aiming to investigate the prevalence of medication errors and the associated factors among Iranian nurses.

METHODS

In this systematic review and meta-analysis, studies were searched on PubMed, Web of Science, Scopus, Google Scholar, IranMedex, Magiran, and SID databases using a combination of keywords and Boolean functions. The study that reported the prevalence of medication errors among nurses in Iran without time limitation up to May 2023 was included in this study.

RESULTS

A total of 36 studies were included in the analysis. The analysis indicates that 54% (95% CI: 43, 65; I2 = 99.3%) of Iranian nurses experienced medication errors. The most common types of medication errors by nurses were wrong timing 27.3% (95% CI: 19, 36; I2 = 95.8%), and wrong dosage 26.4% (95% CI: 20, 33; I2 = 91%). Additionally, the main causes of medication errors among nurses were workload 43%, fatigue 42.7%, and nursing shortage 38.8%. In this study, just 39% (95% CI: 27, 50; I2 = 97.1%) of nurses with medication errors did report their errors. Moreover, the prevalence of medication errors was more in the night shift at 41.1%. The results of the meta-regression showed that publication year and the female-to-male ratio are good predictors of medical errors, but they are not statistically significant(p > 0.05).

CONCLUSIONS

To reduce medication errors, nurses need to work in a calm environment that allows for proper nursing interventions and prevents overcrowding in departments. Additionally, considering the low reporting of medication errors to managers, support should be provided to nurses who report medication errors, in order to promote a culture of reporting these errors among Iranian nurses and ensure patient safety is not compromised.

How Intuitive Is the Administration of Pediatric Emergency Medication Devices for Parents? Objective Observation and Subjective Self-Assessment

BACKGROUND

to assess the intuitiveness of parents' administration of pediatric emergency devices (inhalation, rectal, buccal, nasal, and auto-injector).

METHODS

We invited parents without prior experience to administer the five devices to dummy dolls. We observed whether the parents chose the correct administration route and subsequently performed the correct administration procedures without clinically relevant errors. We interviewed parents for their self-assessment of their own administration performance and willingness to administer devices in actual emergencies.

RESULTS

The correct administration route was best for the inhalation device (81/84, 96% of parents) and worst for the intranasal device (25/126, 20%). The correct administration procedures were best for the buccal device (63/98, 64%) and worst for the auto-injector device (0/93, 0%). Their own administration performance was rated to be best by parents for the inhalation device (59/84, 70%) and worst for the auto-injector device (17/93, 18%). The self-assessment of the correct administration overestimated the correct administration procedures for all the devices except the buccal one. Most parents were willing to administer the inhalation device in an emergency (67/94, 79%), while the fewest were willing to administration procedures the auto-injector device (28/93, 30%).

CONCLUSIONS

Intuitiveness concerning the correct administration route and the subsequent correct administration procedures have to be improved for all the devices examined. The parents mostly overestimated their performance. Willingness to use a device in an actual emergency depended on the device.

Root cause analysis of medication errors of the most frequently involved active substances in paediatric patients

BACKGROUND

Use of medicinal products in paediatric patients is identified as a risk factor for the occurrence of medication errors.

OBJECTIVES

To describe and identify root causes of medication errors in children and adolescents spontaneously reported to Agency for Medicinal Products and Medical Devices of Croatia (Agency).

METHOD

Agency's adverse drug reaction database was searched by using the Standardised MedDRA Query: medication errors (Broad) with data lock point set at 30th June 2022. Cases in which medication errors occurred in patients up to 18 years of age were analysed according to the patients' age group and gender, reporter's qualification, seriousness, reported preferred terms and active substances. For the first 30 most frequently reported active substances, an in-depth analysis was performed to identify the root cause of medication errors.

RESULTS

Altogether, 6254 reports were spontaneously reported to the Agency, out of which 1947 (31 %) contained at least one preferred term belonging to Standardised MedDRA Query medication errors. More than half of patients experiencing medication errors belonged to the age group 2-11 years (66 %) and male gender (53 %). The most frequently reported ME PTs included accidental exposure to product by a child (64 %) and accidental overdose (17 %). Medication error root causes for the first 30 most frequently involved active substances included misinterpretation of prescribed dosage due to a very small volume resulting in salbutamol overdose; replacing millilitre and milligram units resulting in paracetamol solution overdose; interchange between medicinal products due to primary package similarities resulting in cholecalciferol overdose and interchange between oral solution and syrup resulting in valproate overdose.

CONCLUSIONS

Healthcare professionals should counsel caregivers about the importance of keeping medicinal products out of children's reach and provide detailed instructions on how to appropriately use medicinal products.

Health Literacy-Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children: A Randomized Clinical Trial

Importance

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting.

Objective

To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children.

Design, Setting, and Participants

This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis.

Interventions

Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe).

Main Outcome and Measures

Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment.

Results

Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage.

Conclusions and Relevance

A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge.

Trial Registration

ClinicalTrials.gov Identifier: NCT05143047.

Do pediatric oral suspension acetaminophen and ibuprofen product labeling and online resources facilitate intended use?

Background

Caregivers often have difficulty administering pediatric medications which frequently results in increased dosing error risk.

Objective

We examined health literacy characteristics of pediatric over-the-counter (OTC) oral suspension acetaminophen and ibuprofen instructional materials and dosing instruments.

Methods

We conducted a descriptive analysis of dosing instructions, measuring syringe characteristics, and internet-based resources among a sample of OTC pediatric oral suspension acetaminophen and ibuprofen products (n = 14).

Results

All products included Drug Facts Panels, employed consistent abbreviation use, and stated measuring dosage with syringe provided. However, oral syringe dosing increment markings did not match box or bottle dosing charts. Most products had supplemental English-language internet-based content resources available.

Conclusions

While OTC pediatric oral suspension acetaminophen and ibuprofen products labeling included key drug fact elements, there were inconsistencies between medication dosing chart labeling guidelines and oral syringe dosing increments/markings. It is vital that oral dosing syringes are clearly marked to match product dosing chart labeling s as a means of potentially reducing caregiver dosing errors.

Determinants of caregiver's knowledge and practices regarding childhood fever management in a developing setting: a multi-centre cross-sectional assessment

Introduction

Fever is both a sign of various diseases (chief of which are infectious in nature) and an adverse effect of certain interventions (e.g. vaccines, drugs) in the pediatric population. It elicits anxiety among caregivers and healthcare professionals alike resulting in non-evidence based practices, adverse medication administration events, waste of scarce resources and overutilization of health facilities. The determinants of these practices among caregivers in the domiciliary contexts have not been well characterized in developing settings.

Methods

We assessed the knowledge and practices of childhood fever and their determinants among caregivers in domiciliary settings in Northern Nigeria using a 41-item questionnaire between August 2020 and February 2021.

Results

The questionnaire is reliable (knowledge: Cronbach's Alpha = 0.689; practice: Cronbach's Alpha = 0.814) and collected data on a total of 2,400 caregiver-child pairs, who participated in the study. Over two-third (68.3%; 1,640) of the caregivers expressed fever phobic tendencies. Paracetamol was the most commonly used medication and constituted 31.3% of medication administration adverse events reported by the caregivers. Only one out of every six knowledgeable caregivers engaged in evidence-based home childhood fever management practices (7% vs. 41.6%) with being a primary caregiver [Knowledge: odd ratio (OR): 2.81, 95% CI: 0.38; 5.68; p value: 0.04; Practice: OR: 1.65, 95% CI: 0.09; 7.33; 0.02] and having a child/children aged ≤3 years (knowledge: OR: 7.03, 95% CI: 4.89; 9.67, p value: 0.003; practice OR: 3.11, 95% CI: 1.27; 8.59, 0.007) determining both the knowledge and practices of childhood fever management in a household.

Conclusions

The knowledge and practice of childhood fever management among caregivers were sub-optimal with being a primary caregiver and having a child/children aged ≤3 years being the significant determinants of each domain. These gaps underscore the dire need for targeted strategies aimed at improving childhood fever management by educating caregivers.

Safe Care and Medication Intake Provided by Caregivers at Home: Reality Care Study Protocol

JUSTIFICATION

Providing care to patients with several conditions and simultaneously taking several medications at home is inexorably growing in developed countries. This trend increases the chances of home caregivers experiencing diverse errors related with medication or care.

OBJECTIVE

To determine the effectiveness of four different educational solutions compared to the natural intervention (absence of intervention) to provide a safer care at home by caregivers.

METHOD

Prospective, parallel, and mixed research study with two phases. Candidates: Home-based caregivers caring a person with multiple comorbid conditions or polymedication who falls into one of the three profiles of patients defined for the study (oncology, cardiovascular, or pluripathological patients). First phase: Experts first answered an online survey, and then joined together to discuss the design and plan the content of educational solutions directed to caregivers including the identification of medication and home care errors, their causes, consequences, and risk factors. Second phase: The true experiment was performed using an inter- and intrasubject single-factor experimental design (five groups: four experimental groups against the natural intervention (control), with pre- and post-intervention and follow-up measures) with a simple random assignment, to determine the most effective educational solution (n = 350 participants). The participants will be trained on the educational solutions through 360 V, VR, web-based information, or psychoeducation. A group of professionals called the "Gold Standard" will be used to set a performance threshold for the caring or medication activities. The study will be carried out in primary care centers, hospitals, and caregivers' associations in the Valencian Community, Andalusia, Madrid, and Murcia.

EXPECTED RESULTS

We expect to identify critical elements of risk management at home for caregivers and to find the most effective and optimal educational solution to reduce errors at home, increasing caregivers' motivation and self-efficacy whilst the impact of gender bias in this activity is reduced.

TRIAL REGISTRATION

Clinical Trial NCT05885334.

Health literacy in pediatric dermatology: challenges and opportunities

PURPOSE OF REVIEW

Health literacy influences how children and families participate in their medical care, use health services, and overall health outcomes. Health literacy is underexplored in pediatric dermatology. In this scoping review, we provide examples of how limited health literacy can be a barrier to patient care in pediatric dermatology and how to mitigate its effects.

RECENT FINDINGS

Limited health literacy is associated with worse health outcomes, decreased medication adherence, and decreased use of the healthcare system versus those with adequate health literacy. Materials created to help patients understand their medical conditions and treatment options often are written at a reading level far above that of the average patient and caregiver. Given the reading level of patient-facing materials, those with limited health literacy are more susceptible to medication administration errors, with omissions or incorrect dosing being most frequent to occur. There is limited research about how skills related to health literacy, including numeracy and electronic health literacy, can be addressed in pediatric dermatology.

SUMMARY

Health literacy impacts patient care, treatment, and adherence in pediatric dermatology. This article gives examples of how to address common challenges in the pediatric dermatology clinic and presents areas for further research and improvement.

Medication errors in children visiting pediatric emergency departments

OBJECTIVES

Medication safety represents an important challenge in children. There are limited studies on medication errors in pediatric patients visiting emergency departments. To help bridge this gap, we characterized the medication errors detected in these patients, determining their severity, the stages of the medication process in which they occurred, the drugs involved, and the types and causes associated with the errors.

METHODS

We conducted a multicenter prospective observational study in the pediatric emergency departments of 8 Spanish public hospitals over a 4-month period. Medication errors detected by emergency pediatricians in patients between 0 and 16 years of age were evaluated by a clinical pharmacist and a pediatrician. Each medication error was analyzed according to the updated Spanish Taxonomy of Medication Errors.

RESULTS

In 99,797 visits to pediatric emergency departments, 218 (0.2%) medication errors were detected, of which 74 (33.9%) resulted in harm (adverse drug events). Preschoolers were the age group with the most medication errors (126/218). Errors originated mainly in the prescribing stage (66.1%), and also by self-medication (16.5%) and due to wrong administration of the medication by family members (15.6%). Dosing errors (51.4%) and wrong/improper drugs (46.8%) were the most frequent error types. Anti-infective drugs (63.5%) were the most common drugs implicated in medication errors with harm. Underlying causes associated with a higher proportion of medication errors were "medication knowledge deficit" (63.8%), "deviation from procedures/guidelines" (48.6%) and "lack of patient information" (30.3%).

CONCLUSIONS

Medication errors presented by children attending emergency departments arise from prescriptions, self-medicationand administration, and lead to patient harm in one third of cases. Developing effective interventions based on the types of errors and the underlying causes identified will improve patient safety.

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency

Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021.

Methods

This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress.

Results

Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001).

Conclusion

MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.

Medication errors in children visiting pediatric emergency departments

OBJECTIVES

Medication safety represents an important challenge in children. There are limited studies on medication errors in pediatric patients visiting emergency departments. To help bridge this gap, we characterized the medication errors detected in these patients, determining their severity, the stages of the medication process in which they occurred, the drugs involved, and the types and causes associated with the errors.

METHODS

We conducted a multicenter prospective observational study in the pediatric emergency departments of 8 Spanish public hospitals over a 4-month period. Medication errors detected by emergency pediatricians in patients between 0 and 16 years of age were evaluated by a clinical pharmacist and a pediatrician. Each medication error was analyzed according to the updated Spanish Taxonomy of Medication Errors.

RESULTS

In 99,797 visits to pediatric emergency departments, 218 (0.2%) medication errors were detected, of which 74 (33.9%) resulted in harm (adverse drug events). Preschoolers were the age group with the most medication errors (126/218). Errors originated mainly in the prescribing stage (66.1%), and also by self-medication (16.5%) and due to wrong administration of the medication by family members (15.6%). Dosing errors (51.4%) and wrong/improper drugs (46.8%) were the most frequent error types. Anti-infective drugs (63.5%) were the most common drugs implicated in medication errors with harm. Underlying causes associated with a higher proportion of medication errors were "medication knowledge deficit" (63.8%), "deviation from procedures/guidelines" (48.6%) and "lack of patient information" (30.3%).

CONCLUSIONS

Medication errors presented by children attending emergency departments arise from prescriptions, self-medication, and administration, and lead to patient harm in one third of cases. Developing effective interventions based on the types of errors and the underlying causes identified will improve patient safety.

Parental Factors Affecting Pediatric Medication Management in Underserved Communities

BACKGROUND

Medication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities.

METHODS

Using qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis.

RESULTS

Eleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions.

CONCLUSIONS

The compounding effect of these factors - knowledge, communication, resource, and personal belief - may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.

Correct administration aid for oral liquid medicines: Is a household spoon the right choice?

Background

Correct medicine dosing is an important component in the safe and effective delivery of medicines, particularly for the pediatric population. However, there is a scarcity of public campaigns on the correct administration and choice of dosing aids for oral liquid dosage form in many countries, leading to medicine safety issues and therapeutic failures.

Methods

The study targeted the assessment of the knowledge and practice of university students. It utilizes pre- and post-intervention surveys administered through google forms as a survey tool during online zoom and in-person sessions. The intervention included a short video presentation detailing the selection and use of medicine spoons and other aids for the administration of oral liquid dosage. The Fischer Exact test was used to assess the pre- and post-test shift of responses.

Results

Nine-degree programs were engaged in the activity, and 108 students attended this health awareness activity after obtaining formal consent. A significant decline (CI = 95%, ^**** p-value < 0.05) in the choice of selecting tablespoon and a shift to a low-volume spoon, as well as rejection of an entire variety of household spoons, were observed. A significant improvement in the correct naming of spoons, the meaning of the abbreviation "tsp," and the correct volume of a standard teaspoon were also observed with a p-value of <0.001.

Conclusion

A deficit in the knowledge of the proper use of measuring devices for oral liquid medicines in the educated population was observed, which can be enhanced through simple tools like short video presentations and awareness seminars.

Clinical action plans make a difference at point-of-care

PURPOSE OF REVIEW

The purpose of this review is to provide an update to and roadmap for the practical implementation of various point-of-care clinical action plans for primary care providers.

RECENT FINDINGS

Clinical action plans were first developed to address unmet, home preventive needs for the management of asthma. Over the past 10 years, the advancement of mobile health technologies, the recognition of at-risk populations, and the development of evidence-based concepts to guide the creation of patient education tools have expanded the implementation of clinical action plans for many diagnoses (e.g., functional constipation, atopic dermatitis, and headache migraines). Poor patient-related clinical outcomes have been linked with low health literacy for many chronic diseases of childhood. This has served as a call to action to improve patient education. Clinical action plans address this gap by facilitating superior knowledge transfer from the medical team in the clinic to the patient/caregiver. The use of clinical action plans can serve as clinical decision support tools for the medical team and has been demonstrated to improve patient adherence to complex therapy regimens.

SUMMARY

Clinical action plans have the potential to improve disease-related self-management confidence, increase pharmacotherapy adherence, and enhance guideline-concordant care. These clinical decision support tools are safe, inexpensive, and represent an advancement in the high-value care model in pediatric medicine.