Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency

Postoperative Access and Compliance Following Medial Patellofemoral Ligament Reconstruction in Hispanic Adolescents Mirrors the Non-Hispanic Adolescent Population

BACKGROUND

Disparity in surgical care of patellar instability patients has not been fully investigated in the adolescent Hispanic population. This demographic has been shown to have differences in their care, including a lower rate of surgical treatment for patellar instability. Socioeconomic factors have been cited as a factor that influences patient outcomes and its relationship with ethnicity in context of patellar instability has not been evaluated.

METHODS

Review performed of patients <19 years of age who underwent MPFL reconstruction between September 2008 and December 2015. Demographics, patient median household income data, and clinical variables were collected. Generalized linear mixed model (GLMM) with subject as random effects factor was utilized to evaluate differences between ethnicity groups due to nonindependence of data. It was then expanded to incorporate interactions between ethnicity and income.

RESULTS

Ninety-five patellar dislocation events met criteria in 85 adolescents (mean age: 15.5 y). Thirty-four (40%) adolescents identified as Hispanic. In univariate analysis no differences were found between Hispanic and non-Hispanic patients. The multivariate GLMM demonstrated a significant interaction between ethnicity and income. The Hispanic group in the >100% State median income category had the highest rate of postoperative clinic appointments attended (P=0.019). The Hispanic group in the <100% State median income category had the lowest rate of physical therapy appointments attended (P=0.044). No differences were observed for duration of follow-up (P=0.57) or final Kujala score (P=0.75).

CONCLUSIONS

Hispanic ethnicity alone is not associated with inferior postoperative management after MPFL reconstruction in adolescents. However, when socioeconomic status is considered, Hispanic patients of lower-income backgrounds are found to have lower compliance with postoperative rehab recommendations.

LEVEL OF EVIDENCE

Level III.

Creating Culturally Adapted Multilingual Materials for Research

Patients who speak languages other than English are frequently excluded from research. This exclusion exacerbates inequities, biases results, and may violate federal regulations and research ethics. Language justice is the right to communicate in an individual's preferred language to address power imbalances and promote equity. To promote language justice in research, we propose a method to translate and culturally-adapt multifaceted research materials into multiple languages simultaneously. Our method involves a multistep approach, including professional translation, review by bilingual expert panels to refine and reach consensus, and piloting or cognitive interviews with patients and families. Key differences from other translation approaches (eg, the World Health Organization) include omitting back-translation, given its limited utility in identifying translation challenges, and limiting expert panelist and piloting-participant numbers for feasibility. We detail a step-by-step approach to operationalizing this method and outline key considerations learned after utilizing this method to translate materials into 8 languages other than English for an ongoing multicenter pediatric research study on family safety-reporting. Materials included family brochures, surveys, and intervention materials. This approach took ∼6 months overall at a cost of <$2000 per language (not including study personnel costs). Key themes across the project included (1) tailor scope to timeline, budget, and resources, (2) thoughtfully design English source materials, (3) identify and apply guiding principles throughout the translation and editing process, and (4) carefully review content and formatting to account for nuances across multiple languages. This method balances feasibility and rigor in translating participant-facing materials into multiple languages simultaneously, advancing language justice in research.

Association between Paediatric Complementary and Alternative Medicine Use and Parental Health Literacy, Child Health, and Socio-Economic Variables: A Prospective Study

Complementary and Alternative Medicines (CAMs) constitute products and practices not considered allopathic medicine. CAM use is high in children, but little is known about factors that may influence parents using CAM with their child. This study aimed to determine the variables associated with CAM use in children with a prospective study among children and their parents attending a tertiary care hospital in New Zealand (NZ). Outcomes included current CAM use, parental opinions on CAM, parental health literacy and child well-being. This study was completed by 130 parents (85% female), and the mean child age was 6.7 years. CAM use was reported for 59 (45%) children, the most common being oral supplements and body manipulation. Children were more likely to use CAM if their parent had higher health literacy (p = 0.001), and if they had previously attended the emergency department within 12 months (p = 0.03). There was no association between child well-being and CAM use. Parental opinion of using CAM only if a doctor recommended it was associated with CAM use for their child (p = 0.01). Only 40% of parents disclosed their child's CAM use to the medical team. This study highlights that parental health literacy influences the use of CAM for children in NZ, providing insight for translational research to improve CAM safety and disclosure rates in NZ.

Limited English Proficiency can Negatively Impact Disease/Treatment in Children With Cancer Compared to Those Who are English Proficient-an Institutional Study

BACKGROUND

In 2013, 25.5 million people in the United States self-identified as having limited English proficiency (LEP). LEP in adults has been associated with longer hospital stays, increased adverse events, increased emergency room visits, and decreased understanding of medications prescribed. This study aims to define the relationship between LEP and outcomes in a pediatric oncologic population.

METHODS

We performed a matched case-control study utilizing data from our institutional cancer database (children

RESULTS

Twenty-four LEP children were identified and matched with 77 EP children. LEP children represented 11 languages, with the most common being Spanish (42%). Statistical regression demonstrated a clinically significant trend for LEP children to have an increased mean number of unexpected hospital admissions (p = 0.04), increased number of clinic cancellations (n = 0.003), and increased emergency department visits (p = 0.05). LEP children were more likely to have Medicaid than commercial insurance (p < 0.001). There was no difference in 2-year event free or overall survival.

CONCLUSION

In our study cohort, LEP families are at risk for more negative treatment experiences than EP families. Further studies are needed to delineate specific causes and interventions.

TYPE OF STUDY

Retrospective comparative cohort study.

LEVEL OF EVIDENCE

Level III.

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Key Words

• Healthcare disparities
• Limited English proficiency
• Pediatric oncology

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MESH Headings

• Child
• Adult
• Humans
• United States/epidemiology
• Limited English Proficiency
• Cohort Studies
• Retrospective Studies
• Communication Barriers
• Case-Control Studies
• Neoplasms/therapy

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Affiliation(s)

Keyonna M Williams University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA.
Danielle Dougherty University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Connor Plagens University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Nikhil R Shah University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Darrell Tubbs University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Peter F Ehrlich University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA

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Association between YouTube® videos and health literacy with postoperative healthcare utilization following pediatric urologic surgery: A randomized trial

INTRODUCTION

Limited caregiver health literacy has been associated with poorer health outcomes in pediatric patients and may limit caregiver understanding of printed education resources. Postoperative healthcare utilization may be related to confusion about instructions or complications.

OBJECTIVE

To correlate caregiver health literacy and educational video intervention with postoperative healthcare utilization following ambulatory pediatric urologic surgery.

STUDY DESIGN

From July through December 2021, a randomized double-blinded trial assessed postoperative healthcare utilization following pediatric urologic surgery. Caregivers were randomized to receive standardized postoperative counseling and printed instructions (control) or access to English-language educational YouTube® videos with standardized postoperative counseling and printed instructions (intervention). Medical record abstraction was completed 30 days following surgery to identify postoperative healthcare utilization with calls, messages, add-on clinic visits, or presentation for urgent or emergent care, and postoperative complications.

RESULTS

Target enrollment was achieved with 400 caregivers with 204 in the intervention and 196 in the control groups. There was a 32.5 % overall rate of postoperative healthcare utilization. Health literacy was inversely associated with total postoperative healthcare utilization (p < 0.001). There was no difference in the incidence of postoperative healthcare utilization between the control and intervention groups (p = 0.623). However, on sub-analysis of caregivers with postoperative healthcare utilization (Summary Figure), there were fewer total occurrences in the intervention group (intervention median 1, IQR 1,2.3; control median 2, IQR 1,3; p < 0.001). For caregivers with limited health literacy, there was a greater associated reduction in median calls from 2 (IQR 0,2) to 0 (IQR 0,0.5) with video intervention (p = 0.016). On multivariate analysis, total postoperative healthcare utilization was significantly associated with limited caregiver health literacy (OR 1.08; p = 0.004), English as preferred language (OR 0.68; p = 0.018), and older patient age (OR 0.95; p = 0.001).

DISCUSSION

Current resources for postoperative education are limited as resources can be written above recommended reading levels and families can have difficulty recalling information discussed during postoperative counseling. Video intervention is an underutilized resource that can provide an additional resource to families with visual and auditory aids and be accessed as needed.

CONCLUSION

Caregiver health literacy was inversely associated with postoperative healthcare utilization. There was no difference in the incidence of postoperative healthcare utilization with video intervention. However, on subgroup analysis, supplemental videos were associated with fewer occurrences of postoperative healthcare utilization, especially in caregivers with limited health literacy. On multivariate regression, health literacy, preferred language, and patient age were significantly associated with total postoperative healthcare utilization.

Parents' understanding of medication at discharge and potential harm in children with medical complexity

OBJECTIVE

Children with medical complexity (CMC) are among the most vulnerable patient groups. This study aimed to evaluate their prevalence and risk factors for medication misunderstanding and potential harm (PH) at discharge.

DESIGN AND SETTING

Cross-sectional study at a tertiary care centre.

STUDY POPULATION

CMC admitted at Medical University of Vienna between May 2018 and January 2019.

INTERVENTION

CMC and caregivers underwent a structured interview at discharge; medication understanding and PH for adverse events were assessed by a hybrid approach.

MAIN OUTCOME MEASURES

Medication misunderstanding rate; PH.

RESULTS

For 106 included children (median age 9.6 years), a median number of 5.0 (IQR 3.0-8.0) different medications were prescribed. 83 CMC (78.3%) demonstrated at least one misunderstanding, in 33 CMC (31.1%), potential harm was detected, 5 of them severe. Misunderstandings were associated with more medications (r=0.24, p=0.013), new prescriptions (r=0.23, p=0.019), quality of medication-related communication (r=-0.21, p=0.032), low level of education (p=0.013), low language skills (p=0.002) and migratory background (p=0.001). Relative risk of PH was 2.27 times increased (95% CI 1.23 to 4.22) with new medications, 2.14 times increased (95% CI 1.10 to 4.17) with migratory background.

CONCLUSION

Despite continuous care at a tertiary care centre and high level of subjective satisfaction, high prevalence of medication misunderstanding with relevant risk for PH was discovered in CMC and their caregivers. This demonstrates the need of interventions to improve patient safety, with stratification of medication-related communication for high-risk groups and a restructured discharge process focusing on detection of misunderstandings ('unknown unknowns').

Accuracy of liquid drug dose measurements using different tools by caregivers: a prospective observational study

This study aimed to assess the accuracy of liquid drug dose measurements made by caregivers and explore the factors influencing these measurements. Caregivers (n = 176) of children aged less than 8 years, who were treated at the pediatric clinic of a university hospital in Turkey between July and October 2019, were eligible to participate in this study. The caregivers' ability to accurately measure a 2.5-mL dose of medication was observed using standardized measurement instruments, including 15-mL and 30-mL dosing cups, a 3-mL dropper, a 5-mL dose spoon, and a 5-mL oral syringe. A comparison was made with the reference weight determined for the 2.5-mL dose to calculate the margin of error. A dose of ± 20% of the reference value was considered a clinically significant error. The chi-square test was used to examine differences in dose error rates concerning individual characteristics. Caregivers exhibited a dosing error rate exceeding 20%. Specifically, 43% of the errors occurred when using 15-mL cups, 37% with 30-mL cups, 22% with 3-mL droppers, 4.5% with 5-mL spoons, and 4% with 5-mL syringes. In cases where errors were under 20%, the rates were as follows: 1.1% with 15-mL cups, 2.8% with 30-mL cups, 19% with 3-mL droppers, 3.4% with 5-mL spoons, and 4% with 5-mL syringes. The dosing errors were not affected by the role and health literacy level of caregivers, regardless of the type of dosing tool they used (all p values > 0.05). The study found that oral syringes and dosing spoons had the lowest error rates, whereas dosing cups had the highest error rates.  Conclusion: Healthcare providers in family health centers and pediatric clinics should educate caregivers about proper drug administration with oral syringes and dosing spoons, even if dosing cups are included. What is Known: • Dose calculation errors and incorrect measurement tools are the leading factors causing errors. • Liquid medicine bottles are still often accompanied by dosing cups as measuring instruments. • Both the American Academy of Pediatrics (AAP) and the U.S. Food and Drug Administration (FDA) recommend that parents use standard measuring instruments such as oral syringes, droppers, and measuring spoons instead of kitchen spoons for administering the correct dose to children. What is New: • The measuring tool with the maximum errors was the dosing cup, whereas oral syringes and dosing spoons were more accurate. • Individual administering medication at home and the health literacy level had no effect on the accuracy of dose measurement. • Pediatric nurses, in particular, should incorporate safe liquid medication measurement tools into parental education.

Analysis of a Medication Safety Intervention in the Pediatric Emergency Department

Importance

Strategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described.

Objective

To describe implementation of MEDS in routine clinical practice and associated outcomes.

Design, Setting, and Participants

This mixed-methods interrupted time series study of MEDS was conducted April 2021 to December 2022 in an academic pediatric ED using a hybrid type 1 design. Parents and guardians of children aged 90 days to 11.9 years who were discharged with acetaminophen, ibuprofen, or both were eligible for inclusion in the quantitative portion. Clinicians from a diversity of role groups (attending physician, resident, and nurse) were eligible for the qualitative portion.

Exposures

The study was conducted in 5 stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. During the intervention 1 phase, in-depth interviews were conducted until thematic saturation was reached; results were analyzed using thematic analysis. Interviews informed intervention 2 phase interventions.

Main Outcomes and Measures

The primary outcome was any error (defined as dosing or frequency error) at a 48- to 72-hour follow-up phone call.

Results

There were 256 participants (median [IQR] child age, 1.7 [3.0-7.0] years; median [IQR] parent and guardian age, 36.0 [31.0-41.0] years; 200 females among parents and guardians [78.1%]) who consented and completed follow-up. At baseline, 44 of 68 participants (64.7%) made an error compared with 34 of 65 participants (52.3%) during intervention 1, 31 of 63 participants (49.X%) during intervention 2, and 34 of 60 participants (57.X%) during sustainability. After adjustment for language and health literacy, the adjusted odds ratio for error during the combined intervention phases was 0.52 (95% CI, 0.28-0.97) compared with baseline.

Conclusions and Relevance

This study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED.

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.

Measurement of Ambulatory Medication Errors in Children: A Scoping Review

BACKGROUND AND OBJECTIVES

Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability.

METHODS

We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type.

RESULTS

We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability.

CONCLUSIONS

Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.

Assessing perceived and functional health literacy among parents in Cyprus: A cross-sectional study

BACKGROUND

Parents often must take decisions regarding their children's health, which requires certain skills and competences. Parental health literacy (HL) is important in establishing positive health-promoting behaviours and better health outcomes to their children. Limited parental HL has been associated with various negative children's health outcomes. The aim of the study was to explore perceived and functional HL among parents in Cyprus.

METHOD

A cross-sectional study was conducted with a convenience sample of 416 parents of children, aged 6 months to 15 years old, presenting in pediatric outpatient departments across three Cypriot cities. Participants completed the HLS-EU-Q47, a self-reported measure of HL, and the NVS (Newest Vital Sign), a performance-based measure of HL. Associations with socio-demographic characteristics and health behaviors were explored.

RESULTS

Based on suggested ranges, among 416 parents, mostly mothers (83.2%), almost half of parents (42.6%) were classified as having inadequate or problematic perceived HL. Consistently, 62.8% showed high likelihood or significant possibility of limited functional HL, based on the NVS with a mean score of 2.73 out of 6 (SD = 2.02). Nevertheless, no correlation was observed between the two measures of HL. Limited parental perceived HL was statistically significantly associated with lower educational attainment, lower number of children in the family, increased self-assessed health status, and limited exercise habits. Limited parental functional HL was statistically significantly associated with female gender, younger age, lower educational attainment, receiving financial aid, lower family income, and lower alcohol consumption.

CONCLUSION

Even though there was lack of agreement in the classification according to the HLS-EU-Q47 and the NVS, moderate-to-low levels of perceived HL appear consistent with a performance-based measure of HL. As a high number of parents may face challenges in assessing and applying health information to improve outcomes for their children, with evidence of social gradient, healthcare services should be oriented towards identifying problematic HL while Public Health interventions are needed to enhance parental HL.

Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home

PURPOSE

This study aimed to identify the perceptions and attitudes of pediatricians and parents/caregivers regarding medication errors at home, and to compare the findings from the two populations.

METHODS

This was a cross-sectional survey study. We designed a survey for working pediatricians and another one for parents or caregivers of children aged 14 years and younger. The survey's questions were designed to assess provider and parental opinions about the difficulty faced by parents providing medical treatment, specific questions on medication errors, and on a possible intervention program aimed at preventing pediatric medication errors. Pediatrician and parent responses to matching questions in both surveys were compared.

RESULTS

The surveys were administered in Spain from 2019 to 2021. In total, 182 pediatricians and 194 families took part. Most pediatricians (62.6%) and families (79.3%) considered that managing medical treatment was not among the main difficulties faced by parents in caring for their children. While 79.1% of pediatricians thought that parents consulted the internet to resolve doubts regarding the health of their children, most families (81.1%) said they consulted healthcare professionals. Lack of knowledge among parents and caregivers was one of the causes of medication errors most frequently mentioned by both pediatricians and parents. Most pediatricians (95.1%) said they would recommend a program designed to prevent errors at home.

CONCLUSIONS

Pediatricians and families think that medical treatment is not among the main difficulties faced by parents in caring for their children. Most pediatricians said they would recommend a medication error reporting and learning system designed for families of their patients to prevent medication errors that might occur in the home environment.

Reporting of Important Social Determinants of Health in Pediatric Clinical Trials

INTRODUCTION

The objective of this study was to determine the rates and trends in the reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity in published pediatric clinical trials.

METHODS

A cross-sectional study of pediatric clinical trials conducted in the U.S. published from January 1, 2011 through December 31, 2020 in 5 general pediatric and 5 general medical journals with the highest impact factor in their respective fields was performed. Outcomes were reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity. In late 2021, descriptive statistics and logistic regression to understand how reporting of preferred language and socioeconomic factors changed over time were performed.

RESULTS

Of 612 trials, 29.6% (n=181) reported preferred language. Among these, 64.6% (n=117 of 181) exclusively enrolled participants whose preferred language was English. From 2011 to 2020, there was a relative increase in the reporting of preferred language (8.6% per year, 95% CI=1.8, 16.0). Socioeconomic factors were reported in 47.9% (n=293) of trials. There was no significant change in the reporting of socioeconomic factors (8.2% per year, 95% CI= -1.9, 15.1). Only 5.1% (9 of 179) of published trial results among adolescent participants reported any measure of sexual orientation, and 1.1% (2 of 179) reported gender identity.

CONCLUSIONS

Preferred language, socioeconomic factors, sexual orientation, and gender identity were infrequently reported in pediatric clinical trial results despite these characteristics being increasingly recognized as social determinants of health. To achieve more inclusiveness and to reduce unmeasured disparities, these characteristics should be incorporated into routine trial registration, design, funding decisions, and reporting.

Mothers' ability to determine and measure paracetamol doses for children-a contrived observational study

Caregivers are primarily responsible for the administration of Over The Counter (OTC) medications in children. This study examines the mothers' ability to determine and measure paracetamol doses for children aged between 1 and 5 years. A contrived observational study was conducted for mothers of preschool aged children at two Public Health Midwifery (PHM) areas in Southern province, Sri Lanka. Stratified random sampling was used. Only 26.9% (n = 95, 95% CI = 22.5%-31.7%) of the 353 participants correctly determined and measured the doses of paracetamol. Errors were frequently made in both determining and measuring dose together (n = 113, 32.0%, 95% CI = 27.3%-37.1%), determining only (n = 94, 26.6%, 95% CI = 22.2%-31.5%) and measurement only (n = 51, 14.4%, 95% CI = 11.1%-18.5%). Dose determined errors were not significantly associated with maternal education, number of children in the family, total monthly income and age of the index child. Similarly measuring errors were not significantly associated with mothers' education, income of the family and number of children in the family. However, there was a weak positive correlation between measuring errors and age of the index child. The study suggests that mothers made errors when determining doses and measuring doses of paracetamol. Results emphasize importance of clear, concise guardian information leaflet and healthcare professionals' guidance to minimize dosing errors of child medication.

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.

Improving Caregiver Understanding of Liquid Acetaminophen Administration at Primary Care Visits

OBJECTIVES

Liquid medication dosing errors are common in pediatrics. Our outpatient clinic identified gaps in caregiver education based on a 2015 American Academy of Pediatrics policy statement on prescribing liquid medications. This quality improvement (QI) initiative sought to improve caregiver's understanding of liquid acetaminophen administration at the 2-month well-child visit from 30% to 70% over a 32-month period.

METHODS

A resident-led interdisciplinary QI team performed sequential interventions to improve our outcome measure: the percentage of caregivers with an adequate understanding of 4 essential components of liquid acetaminophen administration (name, indication, dose, and frequency). Outcome data were collected via a 4-item verbal assessment of caregiver's understanding by nursing staff, with correct answers to all items considered adequate understanding. Process measures (medications prescribed and education provided), and balancing measures (anticipatory guidance items discussed) were gathered via electronic health record review. Shewhart "P" charts and established rules for detecting special cause variation were used to analyze data. Scatter plots assessed the association between the provision of syringes and caregiver understanding of medication administration.

RESULTS

In 636 caregivers, overall understanding of medication use improved from 39.8% to 74%. Knowledge of accurate dosage improved from 50.9% to 76.8%. Correlation between syringe provision and caregiver understanding was strong (R = .84).

CONCLUSIONS

Resident-led QI improved caregiver's understanding of liquid acetaminophen administration in infants. The most impactful interventions were implementation of English and Spanish pictograms and provision of dose-demarcated oral syringes, coupled with teach-back. Future interventions will examine generalizability to other medications and expansion to other services.

Developing an audio-based communication tool for NICU discharge of Latino families with limited English proficiency

OBJECTIVE

Research shows NICU Latino parents with limited English proficiency (LEP) feel less comfortable asking questions and participating in medical decision-making, which may negatively affect transition to community healthcare. Question prompt lists (QPL), suggested questions sometimes drawn from families and providers, can improve family-centered communication. We explored clinician and parent perceptions to inform development of and pilot a NICU discharge QPL.

METHODS

Focus groups with NICU and primary care providers explored perceived educational needs of Latino parents LEP and barriers to effective transition to community healthcare. Semi-structured interviews with Latino parents LEP explored perceptions of knowledge gaps and recommendations to improve the transition process. A Spanish audio QPL for parents and an English written version for providers were developed and pilot tested for acceptability.

RESULTS

Provider focus groups (n = 27) and parent interviews (n = 19) identified themes: decreased parent activation, knowledge gaps, limited-use interpreters, unfamiliarity with healthcare system, and social isolation as barriers to smooth NICU-to-home transition. Providers (n = 11) and parents (n = 10) favored QPL introduction early in NICU admission, finding it useful to improve communication and transition processes for families.

CONCLUSION

Our QPL may address challenges faced by Latino parents LEP when transitioning home.

PRACTICE IMPLICATIONS

QPLs may improve Latino NICU infants' healthcare outcomes.

Assessing the Availability of Foreign and American Sign Language Interpreting Services in Community Pharmacies

Objective To determine community pharmacists' experience with foreign language and American Sign Language (ASL) interpretation services. Design A survey was drafted to gather information about pharmacists' familiarity with ASL and foreign language interpreting services as well as the frequency with which pharmacists encountered patients who needed these services. Setting Independent and chain community pharmacies in Spokane County, Washington, USA. Participants Fifty-two community pharmacies were identified using a provider-credential search. Fifty-one pharmacists (98%) agreed to participate and completed the survey. Interventions Surveys were initially conducted in person, but after the COVID-19 pandemic began data collection was halted and restarted via phone in accordance with the Washington State University Office of Research Support and Operations. Results Four out of 51 pharmacists surveyed (7.84%) indicated that they were fluent in a language besides English. Pharmacists reported encountering patients who spoke Spanish (31%), Russian (31%), ASL (8%), Arabic (5%), Mandarin Chinese (5%), Vietnamese (5%), Marshallese (5%), and Ukrainian (2%). Some pharmacists (8%) reported not encountering patients who spoke other languages besides English. Most pharmacists (72.5%) indicated their company offered interpreting services for foreign languages, but less than half of pharmacists surveyed (43.1%) had experience using these services. Forty-five percent of pharmacists surveyed did not know whether their company offered an interpreting service for ASL, and only 23.5% indicated that they had experience using ASL interpreting services. Conclusion Pharmacists are less familiar with services for patients who speak ASL and are less likely to have experience with ASL interpretation services than they are to have assisted foreign-language-speaking patients.

A qualitative dual-site analysis of the pharmacist discharge care (PHARM-DC) intervention using the CFIR framework

Introduction

Older adults face several challenges when transitioning from acute hospitals to community-based care. The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits at two large hospitals. This study used the Consolidated Framework for Implementation Research (CFIR) framework to evaluate pharmacist perceptions of the PHARM-DC intervention.

Methods

Intervention pharmacists and pharmacy administrators were purposively recruited by study team members located within each participating institution. Study team members located within each institution coordinated with two study authors unaffiliated with the institutions implementing the intervention to conduct interviews and focus groups remotely via telecommunication software. Interviews were recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Qualitative analysis was performed using an iterative process to identify “a priori” constructs based on CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) and to create overarching themes as identified during coding.

Results

In total, ten semi-structured interviews and one focus group were completed across both hospitals. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at Site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, interviews were conducted with four intervention pharmacists and pharmacists in administrative roles. Three overarching themes were identified: PHARM-DC and Institutional Context, Importance of PHARM-DC Adaptability, and Recommendations for PHARM-DC Improvement and Sustainability. Increasing pharmacist support for technical tasks and navigating pharmacist-patient language barriers were important to intervention implementation and delivery. Identifying cost-savings and quantifying outcomes as a result of the intervention were particularly important when considering how to sustain and expand the PHARM-DC intervention.

Conclusion

The PHARM-DC intervention can successfully be implemented at two institutions with considerable variations in TOC initiatives, resources, and staffing. Future implementation of PHARM-DC interventions should consider the themes identified, including an examination of institution-specific contextual factors such as the roles that pharmacy technicians may play in TOC interventions, the importance of intervention adaptability to account for patient needs and institutional resources, and pharmacist recommendations for intervention improvement and sustainability.

Trial registration

NCT04071951.

Health literacy among visiting college students in the U.S.: A pilot study

Objective This study examined the health literacy of international college students from Colombia visiting the United States. Participants: Thirty (30) students from a Colombian university completed the survey in October 2017. Methods: This pilot study surveyed international college students using the eHEALS and Newest Vital Signs (NVS) health literacy tools to determine the health literacy of this group. Although these students spoke English, a translator was provided. Results: The results show 63% of participants agreed they were confident with filling out health forms alone. In terms of finding helpful health resources on the Internet, 87% of participants felt they knew how to find health information, while 80% felt they knew where to find the resources. Conclusion: There was no association between the health literacy and the confidence of completing forms alone or the perception of using the Internet to answer health questions and knowing where to find helpful resources on the Internet.

The Parent's Perspective: A Focus Group Study on Spanish Interpreter Services for Hospitalized Children

BACKGROUND

The US Census confirms a rise in Spanish-speakers, many of whom have limited English proficiency (LEP) and require interpreters. Parent perceptions of interpreter services throughout hospitalization are unknown.

OBJECTIVE

To explore Spanish-speaking LEP parents' views regarding roles of interpreters and providers (attending, resident, or nurse) during a hospital encounter, optimal modalities of interpretation, and barriers to services.

METHODS

Spanish-speaking LEP parents of children discharged from the hospital medicine service participated in focus groups. Sessions were audio-recorded and transcribed in Spanish, translated into English, and verified for translation accuracy. Qualitative methods were used for thematic analysis.

RESULTS

Four sessions (n = 23 participants representing 15 families) were held. Parents felt the interpreter's primary role was to act as a conduit for word-for-word interpretation. They desired kind and trustworthy interpreters with medical knowledge. They saw providers as leaders of the encounter who should allot enough time for interpretation, not use Spanish unless they were fluent, and give frequent medical updates. In-person interpreters were preferred over telephone and video for their ability to convey body language and build relationships. Barriers to requesting interpreters included embarrassment and inability to directly request services, which resulted in using family members as interpreters. On family-centered rounds, parents preferred professional interpreters over bilingual providers.

CONCLUSIONS

Modifications are required to improve interpreter services to meet the needs of LEP families. Parents emphasized in-person interpreters' social skills, frequent provider updates, and additional navigation support as essential components of effective care. Next steps include implementing guidelines and interventions to optimize interpreter services.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Pathways linking parental health literacy with health behaviours directed at the child: a scoping review

Health literacy (HL) is thought to be crucial for the management of the manifold demands relating to child health which parents are faced with. Albeit many studies have investigated parental HL and health behaviours (HBs) directed at the child, knowledge about the pathways which link parental HL with HB is scarce. The aim of this scoping review was to identify and comprehensively describe the variety of pathways linking parental HL with HBs directed at the child which were empirically analysed in previous studies. Following established scoping review methods database searches were conducted in MEDLINE, EMBASE, PsycINFO and WebofScience on 5 March 2020. Eligibility criteria included primary, empirical studies assessing parental HL and HB directed at the child in the general parent population. Titles and abstracts were screened independently by six reviewers for potentially relevant publications and data were extracted using standardized data extraction forms. The search identified 6916 articles for title and abstract screening. After full-text review, 50 studies were included in this review. Most studies (N = 24) assumed a direct association between HL and HBs and only few studies (N = 4) used more complex models investigating different pathways or mediation and/or moderation models. Overall, the evidence on the underlying pathways linking parental HL and HBs directed at the child is mixed and fairly limited. Therefore, hypothesis-driven research and integration of results into theoretical frameworks is needed for advancing both the research on HL and public health practice.

Association Between English Proficiency and Timing of Analgesia Administration After Surgery

BACKGROUND

Pediatric patients from families with limited English proficiency (LEP) are at risk for health care disparities. We examined timeliness of analgesic administration in pediatric postoperative patients with a limb fracture from LEP versus non-LEP families.

METHODS

This was a retrospective cohort study of children aged 1 year to <18 years of age, hospitalized to the general inpatient floor after surgical correction of single limb fractures between July 2016 and July 2019 were eligible. Patients whose consent was in a non-English language or for whom an interpreter was used were classified as from LEP families. The primary outcome was time to first analgesia. Secondary outcomes included time to first opioid, proportion with any analgesia and opioid analgesia, and number of pain assessments. Associations between LEP and outcomes were tested by using χ² tests, Kaplan-Meier plots, and Cox proportional hazards models.

RESULTS

We examined 306 patients, of whom 59 (19%) were from LEP families. Children in LEP families were significantly less likely to receive any analgesia (86.4% vs 96.8%, P ≤ .01) and experienced longer time to first analgesia in unadjusted (hazard ratio = 0.68, 95% confidence interval: 0.50-0.92) and adjusted analyses (hazard ratio = 0.68, 95% confidence interval: 0.50-0.94). There was no significant association between LEP and time to first opioid, proportion given opioid analgesia, or number of pain assessments.

CONCLUSION

Hospitalized children from LEP families experience a longer time to analgesia administration after surgery. The mechanisms that lead to these differences in care must be identified so that interventions can be designed to address them.

Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency

BACKGROUND AND OBJECTIVES

Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%.

METHODS

Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish.

RESULTS

During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months.

CONCLUSIONS

Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

The Relationship of Parental Health Literacy to Health Outcomes of Children with Medical Complexity

THEORETICAL PRINCIPLES

Children with medical complexity experience negative health outcomes despite the high costs associated with their care. There is growing evidence that low parental health literacy is associated with a number of poor child health outcomes, including medication errors. However, less is known about the relationship between parental health literacy and the health outcomes of children with medical complexity, whose care is known to be more complex and demanding of parents.

PHENOMENA ADDRESSED

The challenges faced by parents of children with medical complexity are presented, including those related to communication, care coordination, and medication administration. The historical and theoretical perspectives of health literacy are discussed, and the relationship of parental health literacy to pediatric health outcomes for children with medical complexity is explored.

RESEARCH LINKAGES

Remaining knowledge gaps about parental health literacy and its influence on the health of children with medical complexity are outlined. Future research and clinical practice implications of health literacy and its importance to family-centered care are discussed.

Association of limited English proficiency and increased pediatric emergency department revisits

OBJECTIVE

Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits.

METHODS

This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted.

RESULTS

There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results.

CONCLUSIONS

These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.

Complexity of Medication Regimens for Children With Neurological Impairment

IMPORTANCE

Parents of children with severe neurological impairment (SNI) manage complex medication regimens (CMRs) at home, and clinicians can help support parents and simplify CMRs.

OBJECTIVE

To measure the complexity and potentially modifiable aspects of CMRs using the Medication Regimen Complexity Index (MRCI) and to examine the association between MRCI scores and subsequent acute visits.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted between April 1, 2019, and December 31, 2020, at a single-center, large, hospital-based, complex care clinic. Participants were children with SNI aged 1 to 18 years and 5 or more prescribed medications.

EXPOSURE

Home medication regimen complexity was assessed using MRCI scores. The total MRCI score is composed of 3 subscores (dosage form, dose frequency, and specialized instructions).

MAIN OUTCOMES AND MEASURES

Patient-level counts of subscore characteristics and additional safety variables (total doses per day, high-alert medications, and potential drug-drug interactions) were analyzed by MRCI score groups (low, medium, and high score tertiles). Associations between MRCI score groups and acute visits were tested using Poisson regression, adjusted for age, complex chronic conditions, and recent health care use.

RESULTS

Of 123 patients, 73 (59.3%) were male with a median (interquartile range [IQR]) age of 9 (5-13) years. The median (IQR) MRCI scores were 46 (35-61 [range, 8-139]) overall, 29 (24-35) for the low MRCI group, 46 (42-50) for the medium MRCI group, and 69 (61-78) for the high MRCI group. The median (IQR) counts for the subscores were 6 (4-7) dosage forms per patient, 7 (5-9) dose frequencies per patient, and 5 (4-8) instructions per patient, with counts increasing significantly across higher MRCI groups. Similar trends occurred for total daily doses (median [IQR], 31 [20-45] doses), high-alert medications (median [IQR], 3 [1-5] medications), and potential drug-drug interactions (median [IQR], 3 [0-6] interactions). Incidence rate ratios of 30-day acute visits were 1.26 times greater (95% CI, 0.57-2.78) in the medium MRCI group vs the low MRCI group and 2.42 times greater (95% CI, 1.10-5.35) in the high MRCI group vs the low MRCI group.

CONCLUSIONS AND RELEVANCE

Higher MRCI scores were associated with multiple dose frequencies, complicated by different dosage forms and instructions, and associated with subsequent acute visits. These findings suggest that clinical interventions to manage CMRs could target various aspects of these regimens, such as the simplification of dosing schedules.

A systematic review on pediatric medication errors by parents or caregivers at home

Introduction: Medication errors (MEs) are frequent and, in some cases, can lead to hospitalization, disability, increased healthcare costs or, even, death. Most of pediatric medications are administered by parents or caregivers at home. It is necessary to explore the MEs at home to improve pediatric patient safety.Areas covered: This study aimed to review the current literature on the frequency of pediatric MEs by parents or caregivers at home, their associated factors, and pediatric ME reporting systems. Citable original articles of any type of study design or reviews published from 2013 to 2021 were searched in Medline, Scopus, Embase, and ScienceDirect databases.Expert opinion: The available data about the frequency of pediatric MEs at home varied from 30% to 80%. Current research suggests the risk of making a ME in pediatric patients at home may depend on the characteristics of the caregiver and may increase if a prescription contains ≥3 drugs. Findings conclude that providing dosing tools more closely matched to prescribed dose volumes, recommending the use of syringes as a measurement tool, and educational intervention for caregivers could be useful to reduce MEs. Concerning the reporting systems for pediatric MEs in the outpatient setting, no information was found.

Can use of pictograms reduce liquid medication administration errors by mothers? An interventional study

Background

Liquid medication dosing errors (LMDE) made by caregivers affect treatment in children, but this is not a well-studied topic in many low-and middle-income countries including in India.

Methods

An intervention study was conducted among mothers attending a pediatric outpatient clinic of a tertiary care setting in Ujjain, India. The mothers randomly measured 12 volumes of a paracetamol liquid preparation by using a dropper (0.5 and 1 mL), measuring cup (2.5 and 5 mL), and calibrated spoon (2.5 and 5 mL) each with two instructions—oral-only measurement session (OMS) and oral plus pictogram measurement session (OPMS, the intervention). The main outcome was dosing error prevalence. The effectiveness of the intervention was assessed by measuring effect size. Risk factors for maximum LMDE were explored using backward multivariate logistic regression models. A P value of < 0.05 was considered statistically significant.

Results

In total, 310 mothers [mean (± SD) age, 30.2 (± 4.18) years] were included. LMDE prevalence in the OMS versus OPMS for dropper 0.5 mL was 60% versus 48%; for l mL dropper was 63% versus 54%; for 2.5 mL cup 62% versus 54%; for 2.5 calibrated spoon 66% versus 59%; 5 mL cup 69% versus 57%; and 5 mL calibrated spoon 68% versus 55%. Comparing OMS with OPMS, underdosing was minimum with the calibrated spoon for 2.5 mL (OR 4.39) and maximum with the dropper for 1 mL (OR 9.40), and overdosing was minimum with the dropper for 0.5 mL (OR 7.12) and maximum with the calibrated spoon for 2.5 mL (OR 13.24). The effect size (d_Cohen) of the intervention OPMS was 1.86–6.4. Risk factors for the most prevalent dosing error, that is, with the calibrated spoon for 2.5 mL, were increasing age of the mother (aOR 1.08; P = 0.026) and nuclear family (aOR 2.83; P = 0.002). The risk of dosing errors decreased with higher education of the mothers.

Conclusions

Pictograms can effectively minimize LMDE even in less educated mothers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00584-9.

NCPDP recommendations for standardizing dosing in metric units (mL) on prescription container labels of oral liquid medications, version 2.0

PURPOSE

Best practices and guidance are provided for standardizing dosing instructions on prescription container labels of oral liquid medications by eliminating use of U.S. customary (household) units and adopting metric units universally, with the goal of decreasing the potential for error and improving safety and outcomes when patients and caregivers take and administer these medications.

SUMMARY

Despite decades of best practice use of metric units in organized healthcare settings and advocacy by various professional societies, medication safety experts, and standards setting organizations, use of household units (e.g., teaspoon) on prescription container labeling instructions for oral liquid medications persists in community pharmacy settings. Five years after publication of the National Council for Prescription Drug Programs' (NCPDP's) original white paper advocating metric-only dosing, very few community pharmacy companies appear to require oral liquid dosing instructions be presented in metric-only units (mL). Error-prone dosing designations contribute to medication errors and patient harm. Use of both multiple volumetric units (e.g., teaspoonsful, tablespoonsful) and multiple abbreviations for the same volumetric units (e.g., mL, cc, mls; tsp, TSP, t) increases the likelihood of dosing errors. Opportunities for error exist with each administration of an oral liquid medication and, unless coordinated with dispensing of appropriate oral dosing devices and optimal counseling, can result in use of household utensils (e.g., uncalibrated teaspoons) or discordantly marked devices that can further exacerbate the risk of error. Since publication of NCPDP's original white paper, new standards have been adopted governing official liquid volume representation, calibrated dosing devices, and e-prescribing software which support the elimination of non-metric units to reduce use of dosing practices that are error-prone. In each case, U.S. customary (household) units have been eliminated in official standards and certification requirements. Therefore, use of non-metric units for oral dosing of liquid medications no longer is an acceptable practice.

CONCLUSION

Key factors contributing to dosing errors with oral liquid medications include use of multiple volumetric units and abbreviations; failure to institute policies and procedures that eliminate the use of non-metric (e.g., household) units and universally adopt metric-only dosing instructions in all settings; failure to coordinate dosing instructions with dosing device markings, appropriate type (oral syringe versus cup), and optimal volumes (e.g., 1-, 5-, or 10-mL devices); failure to adequately counsel patients about appropriate measurement and administration of oral liquid medication doses; and use or error-prone practices such as missing leading zeros and elimination of trailing zeros in prescriptions and container labels. Adoption of this white paper's recommendations will align dosing designations for oral liquid medications in all settings with current standards and attain universal metric-only practice.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency

OBJECTIVES

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families.

METHODS

In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings.

RESULTS

We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters.

CONCLUSIONS

Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children

IMPORTANCE

Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting.

OBJECTIVE

To examine the association between parent LCE and adverse events in a cohort of hospitalized children.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020.

EXPOSURES

Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site.

RESULTS

Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2).

CONCLUSIONS AND RELEVANCE

Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

Training Physician Assistants to Use Medical Interpreters Effectively

PURPOSE

To examine the internal consistency of a validated instrument for physician assistant (PA) communication skills with interpreters and evaluate a training activity focused on effectively working with interpreters during a standardized patient assessment.

METHODS

Six cohorts of PA students completed training on how to communicate with patients who required an interpreter. Students then completed an assessment with a limited English-proficient patient and interpreter. Student competency was assessed using a previously validated measure. Data were analyzed using a multivariable Poisson regression model.

RESULTS

There were usable data on 439 PA students. The median number of areas that students performed/partially performed was 10 out of 12 (inter-quartile range: 3). The Poisson regression model revealed significant differences between cohorts. Areas for further training include using Teach-Back (n = 203) and thanking the interpreter (n = 170).

CONCLUSIONS

Although the PA students performed well, there is considerable room for improvement in certain communication techniques.

Inpatient patient safety events in vulnerable populations: a retrospective cohort study

BACKGROUND

Widespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased risk of patient safety events.

OBJECTIVE

To examine differences in inpatient patient safety events for vulnerable populations defined by race/ethnicity, insurance status and limited English proficiency (LEP).

DESIGN

Retrospective cohort study.

SETTING

Single tertiary care academic medical centre.

PARTICIPANTS

Inpatient admissions of those aged ≥18 years from 1 October 2014 to 31 December 2018.

MEASUREMENTS

Primary exposures of interest were self-identified race/ethnicity, Medicaid insurance/uninsured and LEP. The primary outcome of interest was the total number of patient safety events, defined as any event identified by a modified version of the Institute for Healthcare Improvement global trigger tool that automatically identifies patient safety events ('automated') from the electronic record or by the hospital-wide voluntary provider reporting system ('voluntary'). Negative binomial models were used to adjust for demographic and clinical factors. We also stratified results by automated and voluntary.

RESULTS

We studied 141 877 hospitalisations, of which 13.6% had any patient safety event. In adjusted analyses, Asian race/ethnicity was associated with a lower event rate (incident rate ratio (IRR) 0.89, 95% CI 0.83 to 0.96); LEP patients had a lower risk of any patient safety event and voluntary events (IRR 0.91, 95% CI 0.87 to 0.96; IRR 0.89, 95% CI 0.85 to 0.94). Asian and Latino race/ethnicity were also associated with a lower rate of voluntary events but no difference in risk of automated events. Black race was associated with an increased risk of automated events (IRR 1.11, 95% CI 1.03 to 1.20).

LIMITATIONS

This is a single centre study.

CONCLUSIONS

A commonly used method for monitoring patient safety problems, namely voluntary incident reporting, may underdetect safety events in vulnerable populations.

Interventions to Improve Health among Reproductive-Age Women of Low Health Literacy: A Systematic Review

Background: Limited or low health literacy (HL) has been associated with poor health outcomes, including inadequate self-caring and preventive behaviors. A few studies have systematically summarized the effect of interventions to improve reproductive health and care in women with insufficient HL. The main objective of the study was to investigate health care promotion interventions and examine their effectiveness on women with inadequate HL through a systematic review of randomized controlled trials (RCT). Methods: RCTs and quasi-experimental studies that assessed HL interventions to improve reproductive health of women with low HL were included. The study protocol was registered with PROSPERO (CRD42020137059). Results: Of the 292 records initially identified, a total of 6 articles were included for review. Five different HL screening tools were used. Four different interventions were included: educational intervention, communication skills, a multimedia interactive tool, and text adaptation to enhance reading comprehension. Not enough research practice has been conducted on the influence of interventions on HL, and thus, it is difficult to implement evidence-based interventions. Conclusions: Interventions aiming to benefit and improve HL should consider the complex web of intersectional determinants that end up shaping the opportunities of women to make optimal decisions regarding their health and care, and which may require attention to much more than clinical or service delivery factors.

Medication Education for Dosing Safety: A Randomized Controlled Trial

STUDY OBJECTIVE

This study sought to determine whether a brief intervention at the time of emergency department (ED) discharge can improve safe dosing of liquid acetaminophen and ibuprofen by parents or guardians.

METHODS

We performed a randomized controlled trial in the ED of parents and guardians of children 90 days to 11.9 years of age who were discharged with acetaminophen or ibuprofen, or both. Families were randomized to standard care or a teaching intervention combining lay language, simplified handouts, provision of an unmarked dosing syringe, and teach-back to confirm correct dosing. Participants were called 48 to 72 hours and 5 to 7 days after ED discharge to assess understanding of correct dosing. The primary outcome was defined as parent or guardian report of safe dosing at the time of first follow-up call. Our primary hypothesis was that the intervention would decrease the rate of error from 30% to 10% at 48- to 72-hour follow-up.

RESULTS

We enrolled 149 of 259 (58%) eligible subjects; 97 of 149 (65%) were reached at first follow-up call, of whom 35 of 97 (36%) received the intervention. Among those participants receiving the intervention, 25 of 35 (71%) were able to identify a safe dose for their child at the time of the first call compared with 28 of 62 (45%) of those in the control arm. The difference in proportions was 26% (95% confidence interval [CI] 7% to 46%). There was a 58% increase in reporting safe dosing in the intervention group compared with the control roup (relative risk 1.58; 95% CI 1.12 to 2.24), and it remained significant after adjustment for health literacy and language (adjusted relative risk 1.50; 95% CI 1.06 to 2.13).

CONCLUSIONS

A multifaceted intervention at the time of ED discharge-consisting of a simplified dosing handout, a teaching session, teach-back, and provision of a standardized dosing device-can improve parents' knowledge of safe dosing of liquid medications at 48 to 72 hours.

The safety of health care for ethnic minority patients: a systematic review

INTRODUCTION

Evidence to date indicates that patients from ethnic minority backgrounds may experience disparity in the quality and safety of health care they receive due to a range of socio-cultural factors. Although heightened risk of patient safety events is of key concern, there is a dearth of evidence regarding the nature and rate of patient safety events occurring amongst ethnic minority consumers, which is critical for the development of relevant intervention approaches to enhance the safety of their care.

OBJECTIVES

To establish how ethnic minority populations are conceptualised in the international literature, and the implications of this in shaping of our findings; the evidence of patient safety events arising among ethnic minority healthcare consumers internationally; and the individual, service and system factors that contribute to unsafe care.

METHOD

A systematic review of five databases (MEDLINE, PUBMED, PsycINFO, EMBASE and CINAHL) were undertaken using subject headings (MeSH) and keywords to identify studies relevant to our objectives. Inclusion criteria were applied independently by two researchers. A narrative synthesis was undertaken due to heterogeneity of the study designs of included studies followed by a study appraisal process.

RESULTS

Forty-five studies were included in this review. Findings indicate that: (1) those from ethnic minority backgrounds were conceptualised variably; (2) people from ethnic minority backgrounds had higher rates of hospital acquired infections, complications, adverse drug events and dosing errors when compared to the wider population; and (3) factors including language proficiency, beliefs about illness and treatment, formal and informal interpreter use, consumer engagement, and interactions with health professionals contributed to increased risk of safety events amongst these populations.

CONCLUSION

Ethnic minority consumers may experience inequity in the safety of care and be at higher risk of patient safety events. Health services and systems must consider the individual, inter- and intra-ethnic variations in the nature of safety events to understand the where and how to invest resource to enhance equity in the safety of care.

REVIEW REGISTRATION

This systematic review is registered with Research Registry: reviewregistry761.

Transitions to Outpatient Care After Traumatic Brain Injury for Hispanic Children

BACKGROUND AND OBJECTIVES

Rehabilitation after a child's traumatic brain injury (TBI) occurs in hospital, community, and school settings, requiring coordination of care and advocacy by parents. Our objective was to explore Hispanic parents' experiences during child's transitions of care after TBI.

METHODS

We conducted this qualitative study using semistructured interviews. We used a convenient sample of Hispanic parents of children hospitalized for a TBI in a single level I trauma center. Thematic content analysis using iterative deductive coding and triangulation with clinical data was conducted to identify barriers and facilitators for transitions of care.

RESULTS

Fifteen mothers, mostly from rural areas and with limited English proficiency, participated in the study. Obtaining outpatient rehabilitation was difficult. Barriers included lack of therapists and clinical providers close to home, worsened by insufficient transportation and other support resources; poor understanding of child's illness and treatments; and suboptimal communication with clinicians and school administrators. Facilitators included interpreter use, availability of Spanish written information, and receipt of inpatient rehabilitation. Parents of patients discharged to inpatient rehabilitation reported that observing therapies, receiving school discharge plans by hospital-teachers, and coordination of care were facilitators to access outpatient treatments and to support school return. Parents of children discharged from the hospital from acute care reported need of legal services to obtain school services.

CONCLUSIONS

Hispanic parents, especially those with limited English proficiency, can face significant challenges accessing TBI outpatient rehabilitation and school resources for their children. Although barriers are multifactorial, efforts to improve communication, parent's TBI education, and care coordination during transitions of care may facilitate a child's reintegration to the community and school.

Translating Discharge Instructions for Limited English-Proficient Families: Strategies and Barriers

BACKGROUND

Access to written hospital discharge instructions improves caregiver understanding and patient outcomes. However, nearly half of hospitals do not translate discharge instructions, and little is known about why.

OBJECTIVES

To identify barriers to and potential strategies for translating children's hospital discharge instructions.

METHODS

We conducted a mixed-methods, multimodal analysis. Data comprised closed- and open-ended responses to an online survey sent to Children's Hospital Association language services contacts (n = 31), an online environmental scan of Children's Hospital Association translation policies (n = 22), and county-level census data. We examined quantitative data using descriptive statistics and analyzed open-ended survey responses and written policies using inductive qualitative content analysis.

RESULTS

Most survey respondents (81%) reported having a written translation policy at their hospital, and all reported translating a subset of hospital documents, for example, consent forms. Most but not all reported translating discharge instructions (74%). When asked how inpatient staff typically provide translated discharge instructions, most reported use of pretranslated documents (87%) or staff interpreters (81%). Reported barriers included difficulty translating uncommon languages, mismatched discharge and translation time frames, and inconsistent clinical staff use of translation services. Strategies to address barriers included document libraries, pretranslated electronic health record templates, staff-edited machine translations, and sight translation. Institutional policies differed regarding the appropriateness of allowing interpreters to assist with translation. Respondents agreed that machine translation should not be used alone.

CONCLUSIONS

Children's hospitals experience similar operational and organizational barriers in providing language-concordant discharge instructions. Current strategies focus on translating standardized documents; collaboration and innovation may encourage provision of personalized documents.

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children

BACKGROUND

Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention.

METHODS

We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income).

RESULTS

Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers.

CONCLUSIONS

System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.

Literature review of medication administration problems in paediatrics by parent/caregiver and the role of health literacy

OBJECTIVE

To identify studies that highlighted medication administration problems experienced by parents and children, which also looked at health literacy aspect using a validated tool to assess for literacy.

STUDY DESIGN

Ten electronic databases were systematically searched and supplemented by hand searching through reference lists using the following search terms: (1) paediatric, (2) medication error including dosing error, medication administration error, medication safety and medication optimisation and (3) health literacy.

RESULTS

Of the (1230) records screened, 14 studies were eligible for inclusion. Three analytical themes emerged from the synthesis. The review highlighted that frequencies and magnitudes of dosing errors vary by the measurement tools used, the dose prescribed and by the administration instruction provided. Parent's sociodemographic, such as health literacy and language, is a key factor to be considered when designing an intervention aimed at averting medication administration errors at home. The review summarised some potential strategies that could help in reducing medication administration errors among children at home. Among these recommendations is to show the prescribed dose to the parents or young people along with the verbal instructions, as well as to match the prescribed dose with the measuring tool dispensed, to provide an explicit dose intervals and pictographic dosing instructions.

CONCLUSION

The findings suggest that in order to optimise medication use by parents, further work is needed to address the nature of these issues at home. Counselling, medication administration instructions and measurement tools are some of the areas in addition to the sociodemographic characteristics of parents and young people that need to be considered when designing any future potential intervention aimed at reducing medication errors among children and young people at home.

Reassessing health literacy best practices to improve medication adherence among patients with dyslexia

BACKGROUND

Dyslexia is characterized as unexpected and persistent difficulty in reading. In addition to language-based deficits, evidence indicates that people with dyslexia may struggle with tasks related to memory and executive function. This discussion paper explores how these non-linguistic deficits could plausibly affect medication adherence among patients with dyslexia.

DISCUSSION

There is a dearth of original research literature exploring the intersection of dyslexia and health behaviors in the United States. The authors examine selected best practices from the field of health literacy with potential to improve medication adherence among patients with dyslexia and suggest areas for further research on the intersection of dyslexia, health literacy and medication adherence.

CONCLUSION

Dyslexia is a high-prevalence condition. Patients with dyslexia may be more likely to experience challenges when learning and implementing complex, multi-step health behaviors, such as the tasks associated with medication adherence. However, there has been no research to assess the specific needs of patients with dyslexia, or design interventions to meet those needs. Foundational research is necessary to develop a health communications framework that meets the needs of these neurodiverse patients.

Medication Competence, Numeracy, and Health Literacy

Two studies investigated the association between medication literacy and numeracy. Study 1 revealed an association between both variables in a sample of adults. Study 2 replicated the finding in a sample of parents of young children, even after controlling for level of parental health literacy. Both studies employed the Medication Literacy in Spanish and English (MedLitRxSE) assessment tool. Objective and subjective numeracy scores were significantly correlated with MedLitRxSE scores in both studies, suggesting that interventions for reducing medication errors might benefit by simplifying the numerical information presented in medication instructions. [HLRP: Health Literacy Research and Practice. 2019;3(3):e181–e186.]

Health Literacy: Implications for Child Health

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Audio-Recorded Discharge Instructions for Limited English Proficient Parents: A Pilot Study

BACKGROUND

Parents with limited English proficiency (LEP) demonstrate lower comprehension of discharge instructions. A study was conducted to (1) determine the feasibility of providing a greeting card with language-specific, audio-recorded discharge instructions to LEP parents; (2) describe use of and satisfaction with the cards; and (3) evaluate card effect on instruction comfort with home care and comprehension.

METHODS

LEP parents of children undergoing day surgery from April to September 2016 were eligible. Participants were randomized to usual discharge instructions, or usual instructions plus a three-minute card with language-specific audio instructions that could be replayed repeatedly. Parents were surveyed by telephone two to seven days postdischarge to assess card use and satisfaction, comfort with home care, and discharge instruction recall (medications, home care, follow-up, and return precautions). Parent-reported instructions were compared to instructions in the medical record; concordance was determined by two blinded reviewers. Due to difficulty achieving recruitment goals, analysis focused on feasibility and acceptability.

RESULTS

Of  83 parents enrolled, 66 (79.5%) completed the follow-up survey. Most had not completed high school (61.0%) and spoke Spanish (89.2%). Parents reported high satisfaction with the card (4.5/5 for ease of use, helpfulness, and understandability). Ninety-four percent shared the card with others, and 45.2% reported listening > 5 times. Besides reviewing the care instructions generally, parents reported using the card to review medications and engage others in the child's care.

CONCLUSION

Providing language-concordant, audio-recorded discharge instructions was feasible, and parents reported high satisfaction with and frequent use of the cards with multiple caregivers.

Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging Improvements

OBJECTIVE

To assess the impact of the 2011 changes in pediatric single-ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison control center exposures due to medication errors.

METHODS

National Poison Data System (NPDS) data from January 1, 2007, through December 31, 2016, were used to identify medication error exposures involving single-ingredient liquid acetaminophen in children younger than 12 years of age. Surveys were conducted through 6 regional poison control centers to obtain additional information on a subset of exposures.

RESULTS

The annual frequency of NPDS exposures due to medication errors with single-ingredient liquid acetaminophen products was 8260 ± 670 exposures/year during 2007-2011. Children <2 years of age accounted for 66% of exposures. The overall rate of exposures fell to 6669 ± 662 during 2012-2016 (19% decrease; P = .005). Four percent of exposures led to health care facility referrals. Caregivers involved with exposures in children <2 years of age cited health professionals as the source of dosing information in only 69% of cases despite the absence of specific dosing directions for these children on product labels.

CONCLUSIONS

Implementation of a single concentration for pediatric liquid acetaminophen products and packaging changes were associated with a decrease in medication errors reported to poison control centers. Medication errors are particularly problematic for children <2 years of age, for whom there are no specific labeled dosing instructions. Improved efforts to provide caregivers with dosing instructions for these children are encouraged.