By Melinda Young
EXECUTIVE SUMMARY
A discharge medication communication bundle can help prevent liquid medication errors when caregivers treat children at home after hospital discharge, new research shows.
- The communication bundle resulted in fewer caregivers making medication errors when compared with a group receiving standard care (30.4% vs. 54%).
- Intervention materials included a picture of the oral dosing syringe, medication storage instructions, and a customized table with the medication name and other information.
- The communication bundle could work even more efficiently if it were embedded in the health system’s electronic medical record.
Pediatric medication dosing errors are common and most often occur with liquid medications, which come with dosing complexities. Parents administering the medication at home might lack standardized dosing instruments or may be unable to manage weight-based dosing.
New research shows that a health literacy-informed discharge medication communication bundle can prevent caregivers from making errors when giving liquid medicine to sick children. The randomized clinical trial was performed with caregivers of hospitalized children, ages 6 years or younger. Investigators compared an intervention of a communication bundle with standard discharge counseling.1
The goal is to eliminate medication errors, says Alison Carroll, MD, MPH, lead study author and an assistant professor of pediatrics in hospital medicine at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, TN. The intervention did not achieve that goal, but it did show a significant improvement over standard discharge counseling.
“Only 30.4% of caregivers made any medication errors [in the intervention group], whereas 54% in the standard counseling group made an error,” Carroll says. “It was statistically significant.”
The communication bundle consisted of a printed picture of the appropriately sized oral dosing syringe corresponding to the prescribed dose, along with a customized table with the medication name, indication, dose, frequency, duration, timing for the next dose following discharge, and the most common adverse effects. Medication storage instructions were given. The intervention also included a personalized patient instruction sheet that Carroll created. It was not tied to the electronic health record.
“We have a lot of good evidence that using pictures or plain language in written instructions, as well as teach-back and show-back [techniques], are effective at reducing medication errors,” Carroll explains. “I was the one who delivered the intervention [including] the written medication sheet, which was patient-specific and included the medication’s name, dose, frequency, duration, and what time the next dose was due after the patient left the hospital.”
Carroll taught caregivers how to administer the medication and asked them to teach it back to her. Then, she showed them how to draw up their child’s medication, using the same medication tools they would be using at home.
“I asked them to draw it up and made sure they were drawing up the same volume,” Carroll says. “This group was compared to the group that received the standardized process of bedside nurses printing out an after-visit summary that the electronic health record generates and then reviewing that with the parents.”
Counseling caregivers on medication administration is time-consuming. Often, there are competing demands on staff’s time. “Everyone felt it was important that we counsel families on medications, and people felt that the teach-back method was an important method to use,” Carroll says. “They knew about it but didn’t always do it.”
The show-back method, which also takes time, can be used on any task case managers or clinicians ask caregivers or patients to do when they leave the hospital. “Teach them and show them how to do it and give them the opportunity to practice that,” Carroll says.
As a pediatric hospitalist, Carroll became interested in the discharge process during residency training when she learned about the reality of adverse events related to errors in discharge teaching on medication. “I wanted to focus on what we could do to improve teaching parents and patients about when to take medications when they leave the hospital,” she explains. “There is a real need for us to do a better job of counseling patients.”
Investigators studied the magnitude of the dosing errors, comparing the dose the parents drew to what was in the prescription in the electronic health record. The percentage of those that deviated was not large, Carroll notes. “It still was significantly different, but the differences in doses were not large,” she adds.
Carroll and colleagues did not study adverse events related to the dosing errors. Certain medications have narrow therapeutic indexes, but most medications given by caregivers were antibiotics, where small differences will not affect the children’s health, she explains.
From a clinical perspective, the chief concern is that medication errors can compound and result in health problems. “When you give your child many medications over the course of the day, it could potentially, [even] with small differences, add up and cause harm,” Carroll says. “I couldn’t quantify harm because it’s difficult to measure. But we did show we reduced the dosing errors.”
The next step would be to integrate the communication bundle into the electronic health record to make it easier for case managers, clinicians, and physicians to remember to use. This will take more resources, and it may not be faster. The entire communication bundle only took five minutes to administer.
“The thought is, if this is already integrated into your electronic health record, maybe it could be even shorter,” Carroll says. “With many things in medicine and research, you have to show the value of something before you invest a lot of time or money in fixing things or changing things in the electronic health record.”
More research would be needed to show the benefits of changing the electronic health record. The paper communication bundle could work well as a first step. Carroll’s study is open access and includes examples of the written medication sheets given to caregivers. Training can be done quickly because many providers already have learned health communication techniques, such as the teach-back and show-back methods. “We can re-educate people on them,” Carroll says. “I learned that people were not doing the show-back part because they didn’t feel like they had the supplies. It’s a simple bed bottle with water and syringes. You could have the supplies on the floor to make it easy for people to do that part; it’s an easy fix.”
The show-back method is important because caregivers sometimes lack confidence in handling their children’s medication. While showing caregivers how to draw the medicine, there were times when Carroll had to say, “Yeah, you’re close, but the stopper on the syringe needs to line up here.”
It can be tricky. “It seems straightforward, but it can be hard,” Carroll adds. “Parents said they always had questions about that but never asked or had the opportunity to ask.”
REFERENCE
- Carroll AR, Johnson JA, Stassun JC, et al. Health literacy-informed communication to reduce discharge medication errors in hospitalized children: A randomized clinical trial. JAMA Netw Open 2024;7:e2350969.
A discharge medication communication bundle can help prevent liquid medication errors when caregivers treat children at home after hospital discharge, new research shows. The communication bundle resulted in fewer caregivers making medication errors when compared with a group receiving standard care.
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