Simple Solutions to the
Complicated Problem of
Home Medication Use
Thursday, December 18, 2008
12:00 – 1:00 p.m. EST
© American Academy of Pediatrics 2008
Moderator:
Karen Frush, MD, FAAP
Chief Patient Safety Officer
Duke University Health System
Durham, North Carolina
DISCLOSURES
Financial Relationships
Melissa A. Singleton, MEd, Project Manager-Consultant
has disclosed a financial relationship with an entity producing,
marketing, re-selling, or distributing health care goods or
services consumed by, or used on, patients. Her husband is
employed by Walgreen Co. as a Workforce Administration
Manager (technology position) for the company’s call centers.
The AAP determined that this financial relationship does not
relate to the educational assignment.
None of the other involved individuals (Speaker, Moderator, Project
Advisory Committee members, or Staff) has disclosed a relevant
financial relationship.
Refer to full AAP Disclosure Policy & Grid available below
for download.
DISCLOSURES
Off-Label/Investigational Uses
Our Speaker, Kathleen E. Walsh, MD, MSc, does intend to
discuss an unapproved/investigative use of a commercial
product/device in her presentation.
None of the other involved individuals (Moderator, Project
Advisory Committee members, or Staff) has disclosed
plans to discuss an unapproved/investigative use of a
commercial product/device.
Refer to full AAP Disclosure Policy & Grid available below for
download.
This activity was funded through an
educational grant from the
Physicians’ Foundation for Health
Systems Excellence.
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Category 1 Credit(s)TM from organizations accredited by the
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LEARNING OBJECTIVES
Upon completion of the webinar, participants will be able to:
• Cite the epidemiology of home medication
errors, and what questions remain
unanswered.
• Recognize clinical situations where patients
may be at high risk for home medication
errors.
• Apply at least one strategy to reduce home
medication errors in your patient population.
Speaker:
Kathleen E. Walsh, MD, MSc
Assistant Professor of Pediatrics
University of Massachusetts Medical School
Worchester, Massachusetts
Simple solutions to the
complicated problem of home
medication use
Kathleen E Walsh, MD, MSc
University of Massachusetts
School of Medicine
Case 1

10 mo old with anemia prescribed
– Fer-gen-sol (15mg/0.6 ml) 1.2 ml orally once daily
– Parents given instructions by nurse who spoke some
Spanish
– No one at pharmacy spoke Spanish, bottle labeled in
English

After med, child vomited, appeared ill. ED iron
level 365 mcg/dl (normal 60-180)
 Parent reported administering medication with a
home tablespoon (15 ml)
Outline
 Background
 Home
medication errors
 Unanswered questions and
next steps
Take home points

Even home medication errors are a systems
problem
 There are several simple solutions to help
prevent errors in the homes of your patients
now
 Outpatient quality improvement just getting
started
Background

44,000 to 98,000 patients die a
year from medical errors

21st Century Healthcare System
–Safety
–Effectiveness
–Patient-centeredness
–Timeliness
–Efficiency
–Equity
Definitions

Medication error: error in drug ordering,
dispensing, administering, or monitoring

Adverse drug event: injury that results from
medication use
Adverse drug events and
medication errors
Medication errors
Error
without
adverse
event
Adverse drug events
Adverse
Error
event
with
adverse without
error
event
Swiss cheese model
Reduce human error
1. Person-centered
2. Systems-centered
Reason, J. BMJ 2000; 320(7237): 768-70.
Swiss cheese model
Pharmacy
MD
Parent
No
No interpreter interpreter,
Label in Did not give
Patient receives
Wrong measurement English syringe
overdose
instrument
Outpatient medication pathway
Ordering
Dispensing
Patient
Monitoring
Administering
What’s different about
the home?


Vast majority of US medications taken at home
Liquid medications
– Much more complex to calculate
– Reconstituted from powder
– Measurement devices





Cutting or crushing pills
Vomiting or spitting medicines
Day care or school administration of medications
Risks of over-the-counter medicines
Many children live in poverty
The solution
“Every system is perfectly designed to
achieve exactly the results it achieves”
-Don Berwick
Outline
 Background
 Home
medication errors
 Unanswered questions and
next steps
Methods in existing literature

Medical record review
 Parent interview
 Bring meds to clinic to review
 Demonstration of the dose in clinic
 Home visit
Outpatient pediatric adverse
drug events

Prospective cohort study of 1,788 patients who
had medications prescribed at 6 Boston practices
 Medical record review and parent survey
 3% had a preventable ADE (injury due to an error)
– E.g.: 9 yo with strep prescribed amoxicillin. Parent did
not fill the prescription and child returned with
persistent symptoms

13% had a nonpreventable ADE
– E.g.: 2 yo given cold medicine developed anaphylaxis
Kaushal R, Goldman D, Keohane C, et al. Adverse Drug Events in Pediatric Outpatients. Ambulatory Pediatrics. 2007;7:383-9.
Kaushal R, Goldman D, Keohane C, et al. Adverse Drug Events in Pediatric Outpatients. Ambulatory Pediatrics. 2007;7:383-9.
Outpatient oncology errors

Retrospective review of medical records
 4 oncology clinics in Georgia, New Mexico,
California, and New England
 117 pediatric visits with 913 medications
– 18% had a medication error

1,259 adult patient visits with 10,995
medications
– 7% had a medication error
Walsh KE, Dodd KS, Seetharaman K, et al., Medication Errors among Adults and Children with Cancer in the Outpatient Setting.
Journal of Clinical Oncology. (in press).
Outpatient oncology errors
Monitoring
Other
Order
36%
56%
Administration
Dispense
Outpatient oncology errors

77% of pediatric errors were in medications
used at home
– E.g.: child with ALL and abscess is given
incorrect frequency of antibiotic at home,
abscess does not improve and requires surgical
drainage

7% of adult errors were in medications used
at home
Chemotherapy administration
errors

Prospective observational study in an outpatient
oncology clinic
 Parents asked to bring in the child’s chemotherapy
and demonstrate how they would measure and
administer the dose
– 30% did not bring in some of the chemotherapy

17 errors in 69 patients with 172 medications
– 12 administration and 5 prescribing
Taylor JA., Winter L, Geyer LJ, et al., Oral outpatient chemotherapy medication errors in children with acute
lymphoblastic leukemia. Cancer, 2006. 107(6): p. 1400-6.
Antipyretic dosing by
parent report
Li S, Lathcer B, Crain E. Acetaminophen and ibuprofen dosing by parents. Pediatric Emergency Care 2000;16:394-7.
Chronic acetaminophen overdose
 47
cases of hepatotoxicity after
multiple overdoses of acetaminophen1
– 20 survived, including 4 liver
transplants
– 3 causes: Parent ran out of pediatric
meds and used adult meds, misread
label, fever was high so gave more
medicine
Henretig FM, Selbst SM, Forrest C, et al. Repeated acetaminophen overdosing. Clin Pediatr. 1989 Nov;28(11):525-8.
Acetaminophen dosing
intervention: Color syringes

Color chart, material to help identify their
child’s color, syringe with colored lines
 Compared with conventional methods, less
errors with color syringes
 Average deviation from correct dose 26%
for conventional vs. 1.7% for color syringes
Frush KS, Luo X, Hutchinson P, Higgins JN. Evaluation of a method to reduce over-the-counter medication dosing error. Arch Pediatr
Adolesc Med. 2004 Jul;158(7):620-4.
Dispensing cup: simple
solution or complex problem


34 calls to poison control centers with
dispensing cup errors
3 types:
1. Confusing teaspoon and tablespoon on the
cup
2. Assumption that the dispensing cup was the
unit of measure
3. Assumption that the full dispensing cup was
the actual dose
Litovitz T. Implication of dispensing cups in dosing errors and pediatric poisonings: a report from the American Association of
Poison Control Centers. The Annals of pharmacotherapy 1992; Jul-Aug;26(7-8):917-8.
Simple solution: syringe
with line marked
Prescription and
verbal instructions
2. Prescription with
syringe and
demonstration
3. Prescription, syringe
with a line marked,
and demonstration
1.
1.
37% correct
–
2.
83% correct
–
3.
32%-147% dose
20%-152% dose
100% correct
McMahon SR, Rimsza ME, Bay RC. Pediatrics 1997; 100(3 Pt 1): 330-3.
McMahon SR, Rimsza ME, Bay RC. Pediatrics 1997; 100(3 Pt 1): 330-3.
1970 Home visit study





104 visits to parents recruited from a private
pediatric practice using home medications
Observation of medication administration,
measurement of the home teaspoon, interview
Only 1/3 of teaspoons measure 4.5-5.5 ml
4 parents misunderstood dosing instructions
15 parents were non compliant with instructions
Arnhold, RG, Adebonojo FO, Callas ER, et al., Patients and prescriptions comprehension and compliance with medical instructions
in a suburban pediatric practice. Clinical Pediatrics, 1970. 9(11): p. 648-651.
Cold medicine
Cold medicine toxicity

10 infant overdose deaths; 8 accidental.
Several cold meds involved
 Gunn: 1) overdose in 3 yo with VP shunt; 2)
healthy 3 yo with poor LV function; 3)
repeated overdoses in a healthy 9 mo old
with an at home arrest
 1965-1990: >100 cases of
phenylpropanolamine toxicity, including
several intracranial hemorrhage
Cold medicine effectiveness
1.
RCT: 0.5 to 5 year olds: brompheniramine + PPA +
phenylephrine vs. placebo vs. nothing

2.
RCT: 1.5 to 12 years: codeine vs. placebo vs.
dextromethorphan

3.
No change in symptom scores
Review of trials 1950-1991


4.
No change in symptom scores
2 studies with preschoolers showed no effect.
2 with 6 and older showed some symptom improvement
RCT: 6 mo to 5 years; brompheniramine + PPA vs.
placebo

No change in symptoms, significantly more sleep
Cold medicine solution
Summary of the literature

Rates and types of errors vary by study method
and target population
 Only one study in home where all medicines,
including over-the-counter medicines, and
administration tools can be reviewed
 Parent errors appear to be common
 Parents may be unaware of many errors they make
Outline
 Background
 Home
medication errors
 Unanswered questions and
next steps
Description of the problem

Methods needed to describe the range and types of
home medication errors to target interventions
 Define high risk populations, if any
– Many medications
– Particular disease groups
– SES, other demographic variables
– Low health literacy

One solution may be home visit studies
Patient-centered
communication

1/3 of parents can not accurately repeat back
medication use instructions
 Patients who skip doses, stop taking medications,
and experience side effects do not tell the doctor
 Primary care residency programs reassessing
physician training, pilot testing new methods
 One solution: Need to refocus our outpatient time
and infrastructure to ensure effective
communication about home care
Patient activation




AAP parents guide to children’s
medications
“Ask your doctor to wash his/her
hands”
One solution is email
One practice that used email had
1.2 emails per MD per day. 6%
were urgent, and it was 57%
faster for MD than phone
Rosen P, Kwoh CK “Patient-Physician email: An opportunity to transform pediatric health care
delivery. Pediatrics 2007; 120 (4): 701-706.
Systems to support home care

Pill boxes
 Calendars
 Web based systems
 Telephone based systems
 Support for organization and
compliance
 Real time problem solving
Take home points

Even home medication errors are a systems
problem
 There are several simple solutions to help
prevent errors in the homes of your patients
now
 Outpatient quality improvement just getting
started
Thanks!!
Jerry Gurwitz
Linda Sagor
Bob Klugman
Chris Stille
Kathy Mazor
Doug Roblin
Naheed Usmani, Peter Newburger,
Chris Kaucher,Hellen Mullen
Katie Dodd and Kevin Chysna
Terry Field
Marianne Felice
QUESTION & ANSWER SESSION
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