Parent Medication Administration Errors: Role of Dosing Instruments and Health Literacy

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Isaac Carter
5 years ago
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Schaick, MS Ed, I Bazan, BA, M Kline, MA, BP

1 Parent Medication Administration Errors: Role of Dosing Instruments and Health Literacy HS Yin, MD, MS, AL Mendelsohn, MD, MS Wolf, PhD, MPH, RM Parker, MD, A Fierman, MD, L van Schaick, MS Ed, I Bazan, BA, M Kline, MA, BP Dreyer, MD NEW YORK UNIVERSITY SCHOOL OF MEDICINE

Medication Administration Errors in Children Outpatient medication administration errors are frequent >% caregivers give an incorrect dose of liquid

2 Medication Administration Errors in Children Outpatient medication administration errors are frequent >% caregivers give an incorrect dose of liquid medicine (Frush 4; Li ; Simon 1997; McMahon 1997) Medication administration errors account for % of preventable pediatric outpatient ADEs (Zandieh 8)

Dosing Instruments and Medication Errors Parent choice of measuring device important for dosing accuracy Non-standardized kitchen spoons inaccurate Standardized dosing

3 Dosing Instruments and Medication Errors Parent choice of measuring device important for dosing accuracy Non-standardized kitchen spoons inaccurate Standardized dosing instruments Many types, variability Oral syringes used by health professionals for maximal accuracy Few studies have examined parent ability to dose with the range of available instruments

Health Literacy & Medication Errors In adults, low health literacy has been linked to poor comprehension of Rx labels (Davis 6) non-adherence (Osborn 7; Gazmararian

4 Health Literacy & Medication Errors In adults, low health literacy has been linked to poor comprehension of Rx labels (Davis 6) non-adherence (Osborn 7; Gazmararian 6; Kalichman 1999) Few studies have assessed the role of parent health literacy and medication errors in children Parent ability to use dosing instruments accurately

5 Study Objective To assess rates of parent dosing error by instrument type To examine the role of parent health literacy in the accurate use of dosing instruments

6 Study Design Experimental study Urban public hospital pediatric outpatient clinic Eligibility criteria Parent / legal guardian Responsible for administering medication to child English / Spanish language

7 Predictor Variables Two predictor variables Dosing Instrument Type Caregiver Health Literacy (HL)

8 Predictor Variable: Dosing Instrument Type Let s pretend your child is 3 years old, and has a fever. You find out that the right dose for your child is 1 teaspoon or 5 ml. Please measure this amount using each dosing instrument. CUP #1 CUP #2 SPOON ORAL SYRINGE + PRESS-IN BOTTLE ADAPTER DROPPER ORAL SYRINGE

9 Predictor Variable: Dosing Instrument Type Parents asked to dose 1 teaspoon or 5 ml using 4 types of instruments Order of dosing with each instrument randomized CUP #1 CUP #2 SPOON DROPPER ORAL SYRINGE

10 Predictor Variable: Dosing Instrument Type Parents asked to dose 1 teaspoon or 5 ml using 4 types of instruments Order of dosing with each instrument randomized ORAL SYRINGE + PRESS-IN BOTTLE ADAPTER CUP #1 DROPPER ORAL SYRINGE CUP #2 SPOON

11 Predictor Variable: Health Literacy Caregiver Health Literacy (HL) Newest Vital Sign (NVS) Food label 6 accompanying questions Validated in English and Spanish Categorization Adequate Literacy Possible Limited Literacy Limited Literacy

12 Outcome Variable: Observed Dosing Accuracy Standard bottle of children s acetaminophen suspension % Deviation From Dose Parent Measured Dose Wt compared to Reference Measured Dose Wt Reference Measured Dose Wt = Average Measured Dose Weight of 5mL for 5 pediatricians using the oral syringe Measured Dose Weight = minus Wt of Instrument Containing Measured Dose Pre-assessment Empty Instrument Weight

Instrument Weight % Deviation From Dose Parent Measured Dose Wt compared to Reference Measured

13 Standard bottle of children s acetaminophen suspension Measured Dose Wt = Outcome Variable: Observed Dosing Accuracy Wt of Instrument Containing Measured Dose minus Pre-assessment Empty Instrument Weight % Deviation From Dose Parent Measured Dose Wt compared to Reference Measured Dose Wt Reference Measured Dose Wt = Average Measured Dose Weight of 5mL for 5 pediatricians using the oral syringe

14 Outcome Variable: Observed Dosing Accuracy (cont d) Parent dose considered accurate if within % of reference dose (Yin 8; Kozer 2; Simon 1997) Small error Deviation of >-% from dose Large error Deviation of >% from dose Conservative, compared to USP USP: Standard volumetric error should be within % for dosing instruments

15 Potential Confounders Caregiver Age Relationship to child Language Ethnicity Country of birth SES Child Presence of child <8y in household # of children Presence of child in household with chronic illness

16 Statistical Analysis Unadjusted analyses Chi square Fisher s exact test Multivariate logistic regression analyses Generalized estimating equations

17 Results: Descriptive Data (n=2) CHILD-RELATED Presence of child <age 8 in home # of children (mean (SD)) Presence of child with chronic disease 86% 2.1 (1.2) 32% CAREGIVER-RELATED Caregiver Age (yrs, mean (SD)) Relationship to Child: Mother Caregiver Ethnicity Latino Caregiver non-us born Hollingshead SES Level 4 or (8.6) 95% 8% 76% 8

18 Results: Descriptive Data (cont d) 22% Adequate Literacy Limited Literacy 4 Possible Limited Literacy 37% Parent Health Literacy

19 % Subjects Results: Dosing Errors CUP #1 by Instrument Type 27 CUP # SPOON DROPPER ORAL SYRINGE ORAL SYRINGE + ADAPTER p<.1 Large Error (>%) Small Error (>-%) No Error (within %)

20 Results: Dosing Accuracy Dosing Cups 8 % Subjects 8.3% 2% 28% 44% 18 % 4% 3% 39% 27% >8- >-8.3% >- - >- >- 1 >- 9% >- >-8 >8- = 7% >- CUP #1 CUP #2 = 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

21 8 Results: Dosing Accuracy Dosing Cups Accurate= Within % % Subjects 8 39% 27% >8- >-8.3% 2%.3% >- - >- >- 28% 44% 1 >- 18 % 9% >- 4% >-8 >8- = 3% = 7% >- CUP #1 CUP #2 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

22 8 Results: Dosing Accuracy Dosing Cups Small Underdose Small Overdose % Subjects 8 39% 27% >8- >-8.3% 2%.3% >- - >- >- 28% 44% 1 >- 18 % 9% >- 4% >-8 >8- = 3% = 7% >- CUP #1 CUP #2 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

23 8 Results: Dosing Accuracy Dosing Cups Large Underdose Large Overdose % Subjects 8 39% 27% >8- >-8.3% 2%.3% >- - >- >- 28% 44% 1 >- 18 % 9% >- 4% >-8 >8- = 3% = 7% >- CUP #1 CUP #2 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

24 8 Results: Dosing Accuracy Dosing Cups Large Underdose Large Overdose % Subjects 8 39% 27% >8- >-8.3% 2%.3% >- - >- >- 28% 44% 1 >- 18 % 9% >- 4% >-8 >8- = 3% = 7% >- CUP #1 CUP #2 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

25 Results: Dosing Accuracy Dosing Cups 8 8.3% 2% 28% 44% 18 % 4% 3% 39% 27% >8- >-8.3% >- - >- >- Accurate % Subjects 1 >- 9% >- >-8 >8- = 7% >- CUP #1 CUP #2 = 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

26 % Subjects 8 8 Results: Dosing Accuracy Dosing Cups Large Underdose >8- >-8 Small Underdose.3% 2%.3% >- >- Accurate 1 >- 28% 39% - Small Overdose 44% 27% >- 18 % 9% >- 4% >-8 Large Overdose >8- = = 3% 7% >- CUP #1 CUP #2 3% >- >- Below recommended dose % Deviation From Dose Above recommended dose

27 Results: Dosing Accuracy - Dropper & Dosing Spoon 8 Accurate= Within % 78% % Subjects 8 1 8%.3%.3%.3% 56% = SPOON 38% DROPPER >8- >-8 3% >- >- >- - >- >- >-8 >- >- >- >8- = Below recommended dose % Deviation From Dose Above recommended dose

28 % Subjects 8 8 Results: Dosing Accuracy - Syringes 2% 3% 4% Accurate= Within % % 79% 3 = ORAL SYRINGE ORAL SYRINGE + ADAPTER >8- >-8 2% >- 5% >- >- 12 % - >- >- >-8 >- >- >- >8- = Below recommended dose % Deviation From Dose Above recommended dose

29 % Subjects ORAL SYRINGE 3% CUP #1 CUP #2 4% %.3% 2%.3% % 39% 44% 27% 18% 9% 4% 4% >8- >-8 >- >- >- - >- >- >-8 >8 Below rec. dose Above rec. dose 13% % Deviation From Recommended Dose 8 8 Results: Parent Dosing Accuracy 39% 56% 3% 78% DROPPER SPOON 1 8%.3% >8- >-8 >- >- >- - >- >- >-8 >8 Below rec. dose Above rec. dose

30 Results: Parent Dosing Accuracy - Multivariate Analysis - Dosing Error Defined as >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

31 Results: Parent Dosing Accuracy - Multivariate Analysis - Dosing Error Defined as >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

32 Results: Parent Dosing Accuracy - Multivariate Analysis - Dosing Error Defined as >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

33 Results: Parent Dosing Accuracy - Multivariate Analysis - Large Dosing Error of >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

34 Results: Parent Dosing Accuracy - Multivariate Analysis - Large Dosing Error of >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

35 Results: Parent Dosing Accuracy - Multivariate Analysis - Large Dosing Error of >% Deviation from Dose AOR 95% CI p Dosing Cup # <.1 Dosing Cup # <.1 Dosing Spoon Dropper Syringe+Adapter Oral Syringe Adjusting for caregiver age, ethnicity, language, country of birth, health literacy, SES, rel. to children, # of children, child age, child with chronic disease

36 Results: Accuracy with Standardized Instruments Exploratory Analyses: Dosing Cups & Eye Level Verification No Error Small Error Large Error Eye Level 57% % 14% Not Eye Level 33% 38% % Eye level verification (n=59) Dosing Cup #1: 25% Dosing Cup #2: 38% p=.15

37 Results: Parent Dosing Accuracy - Role of Health Literacy - Any Dosing Error Large Dosing Errors AOR 95% CI p Limited HL Possible Limited HL Adequate HL AOR 95% CI p Limited HL Possible Limited HL Adequate HL Adjusting for instrument, caregiver age, ethnicity, language, country of birth, SES, rel. to children, # of children, child age, child with chronic disease

38 Results: Parent Dosing Accuracy - Role of Health Literacy - Any Dosing Error Large Dosing Errors AOR 95% CI p Limited HL Possible Limited HL Adequate HL AOR 95% CI p Limited HL Possible Limited HL Adequate HL Adjusting for instrument, caregiver age, ethnicity, language, country of birth, SES, rel. to children, # of children, child age, child with chronic disease

39 % Subjects 9 8 CUP # Adequate HL Poss. Lim. HL Limited HL *p=.1 Results: Dosing Errors and Parent Health Literacy by Instrument Type Large Error (>%) Small Error (>-%) No Error (within %) % Subjects 9 8 CUP # Adequate HL Poss. Lim. HL Limited HL *p=.2 % Subjects 9 8 SPOON Adequate HL Poss. Lim. HL Limited HL *p=.1

40 % Subjects % Subjects DROPPER Adequate HL Poss. Lim. HL Limited HL ORAL SYRINGE Adequate HL Poss. Lim. HL Limited HL p=.1 p=.4 Results: Dosing Errors and Parent Health Literacy by Instrument Type % Subjects 9 8 Large Error (>%) Small Error (>-%) No Error (within %) 3 97 ORAL SYRINGE + ADAPTER Adequate HL Poss. Lim. HL Limited HL p=.1

41 Role of Health Literacy in Dosing Errors By Instrument Type Statistically significant Dosing cup #1 Dosing cup #2 Dosing spoon Trend Dropper Oral syringe + adapter No significance Oral syringe

Summary Parent dosing accuracy varies by instrument Fewer errors with droppers dosing spoons, and syringes Dosing cups associated with the most errors;

42 Summary Parent dosing accuracy varies by instrument Fewer errors with droppers dosing spoons, and syringes Dosing cups associated with the most errors; primarily overdosing Parent health literacy also found to be associated with dosing accuracy Greatest association seen for the two dosing cups and the dosing spoon

43 Limitations Dosing assessment performed under experimental conditions, may not reflect caregiver s true ability to dose at home Representative sample of instruments chosen; all dosing instrument variations could not be tested The degree to which the dosing errors found would be associated with adverse clinical outcomes unclear Multiple cutpoints utilized

44 Implications Strategies to decrease medication dosing errors in children should address Accurate dosing instrument use Parent health literacy skills Additional study needed to better understand the factors which relate instrument type to error

45 Acknowledgements Collaborators Benard P. Dreyer, MD Alan L. Mendelsohn, MD Arthur Fierman, MD Linda van Schaick, MS ED Lee M. Sanders, MD Michael S. Wolf, PhD, MPH Ruth M. Parker, MD Additional support Isabel Bazan, Research Coordinator Research assistants Bellevue Hospital Center Pediatric Staff Funding for Research Robert Wood Johnson Physician Faculty Scholars Program Pfizer Fellowship in Health Literacy / Clear Health Communication Dancis Research Fund, NYU School of Medicine Dept. of Pediatrics

46 H. Shonna Yin, MD, MSc Department of Pediatrics NYU School of Medicine / Bellevue Hospital Center 5 First Avenue NBV 8S411 New York, NY 16

ARTICLE. Parents Medication Administration Errors

ARTICLE. Parents Medication Administration Errors ARTICLE Parents Medication Administration Errors Role of Dosing Instruments and Health Literacy H. Shonna Yin, MD, MS; Alan L. Mendelsohn, MD; Michael S. Wolf, PhD, MPH; Ruth M. Parker, MD; Arthur Fierman,