Ability of Saudi mothers to appropriately and accurately use dosing devices to administer oral liquid medications to their children

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.

Putting children first: Understanding caregivers' and children's perspectives on the usability of oral and respiratory administration devices for paediatric medication

A multi-national online survey was developed to obtain feedback on users' experiences of administration devices for oral and inhaled paediatric medicines. The questionnaire was divided into two identical parts: 1) for caregivers looking after children aged 0-18 years, and 2) for children aged 10 years and above, with parental consent. Each part of the questionnaire consisted of a section regarding oral devices and the other about respiratory devices. All data were anonymous and handled and stored in compliance with GDPR. Ethics approval (REC4612-016) was obtained. The study involved eight countries: Albania, Italy, Israel, the Netherlands, Romania, Spain, UK, and USA. A total of 206 adults and 43 children agreed to take part in the survey. Oral dosage forms were more used than inhaled medicines. For oral liquid medicines, oral syringe was the device mostly used by European and Israeli participants. Measuring spoon was the second most common device used, and was also often used in the USA. For respiratory devices, manually actuated and breath actuated metered dose inhalers were the most common everywhere. All devices were deemed easy to use by most of respondents and instructions clear. However, a recurrent suggestion was to simplify device instructions by adding explanatory images and to summarise or highlight key points. Moreover, respondents proposed other improvements related to device appearance and design that would make the device more acceptable for them to use. Understanding paediatric patients and caregivers' experiences about oral and respiratory devices is key to provide industry with information that can help improve the use and acceptability of administration devices. Aspects that device suppliers and healthcare professionals would need to prioritise are the provision of simpler instructions in the form of images and key summaries, and to provide adequate training on device use. These improvements are essential to ensure that children and caregivers are able to use the device appropriately.

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.

Usability of administration devices for oral and respiratory medicines: views from a UK primary school

The correct use of medicine administration devices is pivotal for optimal drug therapy in children. Little is known about end users' perspectives on administration device use. Thus, the aim of this study was to conduct a survey to gain information and opinions from caregivers and children regarding the usability of paediatric medicine administration devices. A survey was conducted at a primary school in the United Kingdom in children aged 10-12 years and their caregivers. It focused on oral and respiratory devices and comprised two identical parts: 1) for the caregivers, 2) for the children with parental consent. Ethics approval (REC4612-016) was obtained. A total of 57 caregiver-child pairs accessed the survey and it was completed by parents only (n=4), children only (n=31) or jointly (n=22). Most participants (65%) had taken liquid dosage forms (e.g., syrups/suspensions) compared to solid dosage forms (34%). Oral devices most frequently used were oral syringes (42%), measuring spoons (22%), and household spoons (18%), with parents most frequently demonstrating device use to their children. Respiratory devices were used less frequently, and pressurised metered-dose inhalers with/without spacer (pMDIs) were the most commonly used devices (11/13). Instructions on use were provided by healthcare professionals to both caregivers and children. Generally, oral and respiratory devices were considered easy to use and instructions were clear. However, for both oral and respiratory devices, some suggestions for device improvement were provided by participants. Education/training by healthcare professionals and clear supplier instructions (e.g., pictograms) may be especially effective in ensuring that caregivers and children are able to use administration devices appropriately and receive sufficient information on their correct use.

The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study

Introduction

Patient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.

Methods

A quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.

Results

A total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).

Conclusion

Limited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.

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.

Medical Device-related Counseling Practice and Barriers among Sudanese Pharmacists: A Questionnaire-Based Study

Objective:

The aim of the present study was to assess medical devices-related counseling practice and barriers among pharmacists.

Methods:

This was a cross-sectional study conducted using a convenient sample of Sudanese pharmacists. An online-version survey was used to collect data.

Findings:

One hundred and thirty pharmacists responded to the online survey. Most pharmacists in this sample were master or Ph.D. degree holders (62.3% and 12.3%, respectively), having a clinical training experience (70%) and substantial proportion are board-certified (30%). Medical devices reported to be commonly inquired by patients were blood glucose monitors, nebulizers, blood pressure monitors, dry powder inhalers, and insulin pens. Devices most frequently requiring counselling were blood glucose monitors, blood pressure monitors, syringes, thermometers, nebulizers, dry powder inhalers, insulin, and weighing scales. The most frequently supplied devices reported were syringes, blood glucose monitors, insulin pens, blood pressure monitors, thermometers, nebulizers, and dry powder inhalers. Devices least frequently requiring counselling were implanted devices, respirometers, and stethoscopes. The least frequently supplied devices were respirometers, implanted devices, and heart rate monitors.

Conclusion:

Medical devices reported to be commonly inquired by patients were most frequently requiring counseling, and most frequently supplied. Findings reflect the availability of devices in the market and pharmacists' response to the needs of their patients. Pharmacists should maintain adequate knowledge about the proper use of medical devices because this is a common patient inquiry.

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.

Dosing Accuracy of Oral Extemporaneous Suspensions of Antibiotics: Measuring Procedures and Administration Devices

Extemporaneous suspensions are often marketed with several administration devices that can be freely used by patients/caregivers. The homogeneity of suspensions requires shaking before use. Hence, it is crucial to assess the precision of all devices and the users’ awareness of the shaking procedure. This study was conducted at University Institute Egas Moniz with 40 pharmacy students who were asked to measure 2.5 and 5 mL of two extemporaneous azithromycin suspensions. Formulation A is marketed with a double-dosing spoon and oral syringe, whereas B includes a transparent dosing spoon. Both have a reconstitution cup. The user’s preference for administration devices, the degree of compliance with the ‘shake before use’ instruction and the accuracy of the manipulation were assessed. The double-dosing spoon was the preferred device. The “shake before use” instruction was overlooked by most volunteers. The average measured volumes obtained with the double-dosing spoon were significantly different from the ones obtained with the oral syringe (p < 0.001) and significantly lower than the reference dose (p < 0.001). The oral syringe originates significantly higher values than the reference dose (p < 0.001). The dosing spoons values were significantly different from each other (p < 0.001). Liquid medicines containing several administration devices may be a challenge since they are nonequivalent.

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

BACKGROUND

Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries.

METHODS

A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included.

RESULTS

Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5-16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists' interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists' recommendations.

CONCLUSIONS

Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.

Administration of oral medication by parents at home

AIMS AND OBJECTIVE

The objective of this study was to determine parents' experiences and problems with administering medication to their children at home.

BACKGROUND

Parents' experiences and access to information for the treatment of their children's illnesses at home is necessary for their children's safety.

DESIGN

A descriptive cross-sectional study.

METHODS

Four hundred parents from children's hospital outpatient clinics were included. A questionnaire was used to determine parents' experiences and problems with administering medication to their children at home. Descriptive statistical analyses were performed using the spss software package (version 22.00).

RESULTS

Antipyretics (59%) and antibiotics (25%) were the most commonly used medicines by parents without prescription. Nearly half of the parents stated that they gave liquid medicine with a household spoon. It was found that 54% of the parents whose children refused to take tablets or liquid medicine mixed these medications into foods. Treatment was delayed in 20·7% of the children who refused to take tablets and in 29·1% of the children who refused to take liquid medicine. As a result of the project, a form and device were developed as a solution to the problems experienced by parents while administering oral medication in the home environment.

CONCLUSION

The results of the study showed that a significant percentage of the parents did not use the correct equipment to administer medications, used non-prescription medicines, did not administer medications at correct intervals and mixed medication into foods.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals, especially nurses, should continually evaluate medication administration by parents at home and the readmission rate in the emergency department to further improve children's health.

Improving pediatric liquid medication labeling of the hospital information system in Malaysia: qualitative analysis of pharmacists' perceptions

Background:

Inadequacies of drug labeling have been frequently reported among Malaysian healthcare institutes, in which the Hospital Information System (HIS) is used.

Objective:

To identify potential areas to improve the existing labels used for pediatric liquid medications.

Methods:

This study was qualitative in nature, whereby focus group discussions (FGDs), face-to-face interviews (FTFIs), and onsite observation were used for data collection. Pharmacists stationed at three units (outpatient, inpatient and clinical pharmacy) of a tertiary hospital were targeted. Both FGDs and FTFIs were facilitated using a semi-structured interview guide, video-recorded and transcribed verbatim. All transcripts were thematically analyzed using content analysis approach.

Results:

Thirteen pharmacists participated in FGDs, while five were approached for FTFIs. Data analysis resulted in four major themes: format of labels, presentation of medication instructions, insufficiency of information, and the need for external aids and education. Participants unanimously agreed on the need for enlarging font sizes of key information. Suggestions were made to use more specific instructions for administration times and pictograms to illustrate important directions. The absence of information about storage, stability and handling of liquid medications was also highlighted. While discussion mainly focused on improving drug labeling, participants consistently stressed the need for an instruction sheet and pharmacist-based, one-to-one education regarding medication instructions.

Conclusion:

This study provides important insights into critical shortcomings in current labeling practice, underlying the need for developing a new label that incorporates a new format, additional information and pictograms for pediatric liquid medications.