Errors and Nonadherence in Pediatric Oral Chemotherapy Use

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.

Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review

INTRODUCTION

Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices.

AREAS COVERED

This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products.

EXPERT OPINION

The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.

Safer Type 1 Diabetes Care at Home: SEIPS-based Process Mapping with Parents and Clinicians

Introduction

The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D.

Methods

A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA).

Results

Eight (57%) of the 14 children who had home visits experienced 18 errors (31 per 100 medications). Four errors in two children resulted in harm, and 13 had the potential for harm. Two injuries occurred when parents failed to treat severe hypoglycemia and lethargy, and two were due to repeated failures to administer insulin at home properly. In SEIPS-based process maps, high-risk errors occurred during communication between the clinic and home or in management at home. Two FMEAs identified interventions to better communicate with families and support home care, especially during evolving illness.

Conclusion

Using SEIPS-based process maps informed by multimodal methods to identify medication errors and treatment delays, we found errors were common. Better support for managing acute illness at home and improved communication between the clinic and home are potentially high-yield interventions.

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: A multisite longitudinal assessment

BACKGROUND

There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. We aimed to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over 7 months of treatment.

METHODS

We recruited children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Errors were identified by chart review, in-home medication review, observation of administration, and interviews. Physician reviewers confirmed error (Fleiss' κ = 0.95), harm (Fleiss' κ = 0.82), and suggested interventions. Generalized linear mixed models with random effects were used to account for clustering by site.

RESULTS

Among 131 children taking 1669 medications with 367 home visits, 408 errors were identified, including 242 with potential for harm and 39 with harm (1.0 harm per 1000 patient-days [95% CI, 0.1-9.8]). Ten percent of children were injured by errors and 42% had errors with potential for harm. Twenty-six percent of caregivers reported that miscommunication led to missed doses or overdoses at home. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%).

CONCLUSIONS

In this longitudinal study, 10% children with leukemia or lymphoma experienced adverse drug events because of outpatient medication errors. Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

PLAIN LANGUAGE SUMMARY

In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

A Cell-Phone Medication Error eHealth App for Managing Safety in Chronically Ill Young Patients at Home: A Prospective Study

Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.

Improved home management of oral pediatric anticancer drugs as a result of an intervention comprising practical training, written instructions and movie clips: A pilot study

BACKGROUND

Long term treatment of pediatric patients with oral anticancer drugs (OADs) requires the parents/caregivers to prepare the drug at home. The handling procedures in the home setting are, however, not regulated by Swedish law and the parents are often left without guidance on how to handle OADs in a safe way.

AIM

The aim of this study was to increase understanding of how OADs are handled by parents/caregivers in the home setting before and after an intervention.

METHODS

Parents of pediatric cancer patients were observed and videotaped during their handling of OADs in the home setting before and after the intervention. During the intervention, the parents were provided with written instructions, movie clips and practical training on handling the OADs. Four checklists were used to compare and score the four handling procedures (measuring an oral suspension, cutting tablets, dissolving tablets, and opening capsules) for each parent before and after the intervention.

RESULTS

The intervention significantly improved the OAD handling procedures among the studied parents. The median score for correct handling was 19% (IQR: 3.6 to 30%) before the intervention and 89.5% (IQR: 71.5 to 94.5%) after the intervention (p < 0.0001).

CONCLUSIONS

An intervention comprising practical training and information presented in different forms improved the handling of OADs at home by parents. There is an urgent need to implement this method in all oncology centers in Sweden, educate HCPs to standardize the presentation of information. There is also a great need to provide parents with age-appropriate oral drug formulations from the local hospital pharmacies in Sweden.

Medication Errors in Adolescents Using Asthma Controller Medications

The purpose of this study was to describe the number and types of errors that adolescents and caregivers report making when using asthma controller medications. A total of 319 adolescents ages 11 to 17 with persistent asthma and their caregivers participated in this cross-sectional study. Adolescent and caregiver reports of asthma medication use were compared to the prescribed directions in the medical record. An error was defined as discrepancies between reported use and the prescribed directions. About 38% of adolescents reported 1 error in using asthma controller medications, 16% reported 2 errors, and 5% reported 3 or more errors. About 42% of caregivers reported 1 error in adolescents using asthma controller medications, 14% reported 2 errors, while 6% reported 3 or more errors. The type of error most frequently reported by both was not taking the medication at all. Providers should ask open-ended questions of adolescents with asthma during visits so they can detect and educate families on how to overcome errors in taking controller medication use.

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.

Assessment of the Role of the Pediatric Nurse in Patient Education and Follow-up of Patients Receiving Oral Anticancer Treatment

Objective: To assess the role of the pediatric nurse/advanced practice provider in patient education and follow-up of patients receiving oral anticancer therapy. Methods: Association of Pediatric Hematology/Oncology Nurses members were invited to participate in a survey that focused on the nurses' roles in patient education of patients taking oral oncolytic agents. Data were collected via a 16-item questionnaire. Respondents included 197 nurses and advanced practice providers. Content analysis techniques were used to describe the qualitative data while Fisher's exact test and chi-square test were used in the quantitative statistical analysis. Results: Seventy-one percent of respondents reported some type of involvement in patient education. Knowledge as well as comfort level improved as years of oncology nursing experience increased. Generally, policies and procedures are in place; however, nurses noted there is a need for improved oral oncolytic guidelines. Nurses also reported a need for improved and updated educational resources. Conclusion: While the development of oral oncolytic agents continues to rise, findings show a need to develop evidence-based guidelines for nurses, which include management of oral oncolytic dosing, adverse events, and safety issues.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Objective

To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports.

Methods

We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns.

Results

We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features.

Conclusions

Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Content review of pediatric ethics consultations at a cancer center

BACKGROUND/OBJECTIVES

Ethical challenges in pediatric oncology arise at every stage of illness. However, there are sparse data on the content of and reason for ethics consultations in the field. We sought to evaluate the content and characteristics of ethics consultations in pediatric patients at a cancer center.

DESIGN/METHODS

We retrospectively identified ethics consultations performed for patients diagnosed with cancer at ≤21 years of age who were treated in the Department of Pediatrics from 2007 to 2017. Using an established coding schema, two independent reviewers analyzed the content of ethics consultation notes and identified core ethical issues and relevant contextual issues. Demographic, clinical, and consultation-specific data were also collected.

RESULTS

Thirty-five consultations were performed for 32 unique patients. The most commonly identified ethical issues were obligation to provide nonbeneficial treatment (29%) and resuscitation preferences (26%). Communication conflicts were the most commonly identified contextual issue (40%). There were two themes that emerged repeatedly but were not a part of the original coding schema-four consultations (11%) that involved physicians questioning their obligation to provide potentially toxic treatment in the setting of poor patient/parent compliance, and two consultations (6%) related to complex risk-benefit analysis in the setting of an invasive procedure with uncertain benefit.

CONCLUSIONS

Pediatric ethics consultations are infrequent at this specialty cancer hospital. Ethical issues focused on treatment and end-of-life care and included a diversity of communication conflicts.