homes: home medication support
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Home Care in Children
Kathleen E Walsh MD MSc, Colleen Biggins, Christopher Keuker MD, Shira Fischer, Kathleen Mazor EdD MSc
Supported by Picker/Gold Challenge Grant
• 10 yo with leukemia on 6.5 tabs 6MP– Mother cuts pills with knife, rather than pill cutter– Crumbles pills – Child leaves ½ pill pieces on table unconsumed
• MD tells mother to increase antiepileptic doses due to increased seizures– Mother misunderstands and does not increase dose
• A child on chronic steroid treatment has chest and abdominal pain/burning– Diagnosed with gastritis by his PCP given ranitidine– Mom never filled prescription– Chest and abdominal pain continue for months
Clinical CasesClinical Cases
Learning objectives
1. Residents will know what difficulties children and families experience in home medication use and will identify child and family risk factors for these difficulties
2. Residents will develop skills in inquiring about home medication use, identifying difficulties, and working with families to develop systems-based solutions to prevent problems
3. Residents will change their behavior to routinely identify families at risk for problems in home care in their clinical practice and work with families to develop strategies to prevent problems
Why is support for home care Why is support for home care importantimportant
• Trend toward increased chronic disease care in medicine in general
• Shift from inpatient to outpatient care• “Medications don’t work if patients don’t take
them” – C. Everett Koop MD
DefinitionsDefinitions• Medical error: the failure of a planned action to take place as
intended or the use of a wrong plan to achieve an aim• Medication error: error in drug ordering, dispensing, administering or
monitoring• Adverse drug event: injury resulting from medication use
Error without adverse event
Adverse event without error
Error with adverse event
Medication errors Adverse drug events
Missed doses and regimen complexity in adult patients
•For once daily dosing,20% adults missed doses of medication (also known as nonadherence)
•Number patients with missed doses increases as frequency of dosing increases
•This study evaluates adult adherence to a very simple regimen,pills for a single medication in adults
•Home regimens for childrenon multiple medicines including liquid medications taken many times a day are more problematic
Osterberg L, Blaschke T, N Engl J Med 2005;353:487-97.
Comparison of pediatric and Comparison of pediatric and adult medication errors found in chart review at 4 adult medication errors found in chart review at 4
Cancer Research Network sitesCancer Research Network sites, N=1379 clinic visits
Walsh KE, Dodd KS, Seetheraman K, et al. Journal of
Clinical Oncology 2009;6:891-896.
4.3
14.5
5.8
0.7
0
2
4
6
8
10
12
14
16
Clinic Home
Pediatrics
Adults
Rat
e of
err
ors
per
100
clin
ic v
isits
Home visit methods
Identification of Strategies to Prevent Errors
Home Visit: Direct Observation* Review of Medications Parent Interview
Physician Review of Possible Errors
Obtain diagnoses and medication list from medical record
* Interobserver reliability (kappa)= 0.72 (95% CI: 0.4-1)
Walsh et al. Using home visits to understand medication errors in children. Vol. 4. Technology and Medication Safety: Agency for Healthcare Research and Quality, August 2008.
Errors found in 60% of homes Errors found in 60% of homes during home visitsduring home visits
Sickle Cell
(N=25)
Epilepsy
(N=28)
Cancer
(N=27)
Number of medications 119 154 290
Number errors 41 28 52
Rate error per 100 medications (Confidence Interval)
With injury
No injury but potentially dangerous
Trivial
34.4 (25.9-42.9)
6.7
17.6
10.1
18.1(11-25.2)
0.7
8.4
9.1
17.9(12.4-23.7)
1.4
11.0
5.5
Overall, 60% of children had a medication error found on a home visit
Parent use of support tools associated Parent use of support tools associated with significantly less errorswith significantly less errors
No supports Supports
At least one error at home
19 14
No error 1 18
* X2=13.9 (p=0.0002)
Support tools parents used at home to prevent mistakes in medication use in children
with chronic disease
Encourage parents to use something at home to prevent mistakes:Anything is better than nothing
Risk factors for home medication Risk factors for home medication errorerror
• More medications = more mistakes1
• Regimens that fit with a normal routine work better2
– Some parents really do set their alarms to give middle of the night doses of medicine
• Low health literacy or non-English speaking may not be a clear association appendix
• People who know what their medicine is for are more likely to use it3
1. Holdsworth, Arch Pediatr Adolesc Med. 20032. Field T, Mazor K, Briesacher B, et. al., Journal of the American Geriatrics Society. 2007
3. Fletcher S, Fletcher R, Thomas D, et. al. Journal of Community Health. 1979
More medications = more mistakesMore medications = more mistakes
More complex regimens are more prone to errorMore complex regimens are more prone to error
Communication problems Communication problems leading to errorleading to error
• Adult patients do not tell their doctors about home changes in dose, missed doses, side effects1,2,3
• 60% of children with chronic conditions are given medicine by multiple difference caregivers4
– We found: Mom, Grandma, aunts, babysitter, Dad, parents roommates, others
1. Field TS, Mazor KM, Breisacher B, et. al., J Am Geriatr Soc 2007 2. Bedell S, Jabbour S, Goldberg R, et. al., Arch Intern Med 2000 3. Weingart S, Gandhi T, Seger, et. al., Arch Int Med 2005 4. Walsh K, Mazor K, Stille C, et. al., Arch Dis Child in press
Prevention:Prevention:Have parents bring in medicationsHave parents bring in medications
• Review bottle labels for dispensing errors
• Ask parents how they give each medicine
• Check if needs refills• Look at fill date and
roughly count pills to see if missing many doses at home– E.g. 2006 fill date on 30
day supply bottle with 3 pills left in 2009 indicates missed doses
Group Prescription and verbal
instructions Prescription with syringe
and demonstration Prescription, syringe with
a line marked, and demonstration
How they did1. 37% correct dose
2. 83% correct
3. 100% correct
McMahon SR, et al. Pediatrics 1997; 100(3 Pt 1): 330-3.
Prevention of measurement error:Prevention of measurement error:Syringe with line marked & demonstrate doseSyringe with line marked & demonstrate dose
Parents of children 0-4 y.o. with otitis media randomized to different groups.Parents filled antibiotic prescriptions then returned to show how they wouldmeasure medicine at home.
Prevention: ALWAYS…Prevention: ALWAYS…
• Say what the medication is for
• Say how to give the medicine
• Ask if there are any questions
Problem Recommendation
Acetaminophen or ibuprofen under dosing
Review dose at every visit
Failure to change doses or fill prescriptions
Ask parent to bring in all medications; ask about dose, timing, preparation
Problems giving medications at home
Ask about problems giving medication: general problems/refusals? vomiting? missed doses?
Prevention:Prevention: Doctor-parent brief communication guideDoctor-parent brief communication guide
Prevention:Prevention: Doctor-parent brief communication guideDoctor-parent brief communication guide
Problem Recommendation
Miscommunication between in home caregivers (parents, parent and babysitter, others)
•“Who gives medicines at home?”•multiple people?•Do parents have a:
1.System for communicating about changes
2.System for tracking whether a medication has been given?
General Encourage to contact the clinic with any problems with medications
Provide instructions if problems/questions occur outside of office hours
No support tools •“Do you use anything at home to help you give medicines?” pill box? alarms?•If no, suggest tools•Offer help getting started with tool
Prevention:Prevention: Doctor-parent brief communication guideDoctor-parent brief communication guide
• Please identify 3-5 patients in your practice who are at risk for home medication errors
• Please print the communication guide and try it with them
Link to Brief Communication Guide for doctors
Learning objectives
1. Residents will know what difficulties children and families experience in home medication use and will identify child and family risk factors for these difficulties
2. Residents will develop skills in inquiring about home medication use, identifying difficulties, and working with families to develop systems-based solutions to prevent problems
3. Residents will change their behavior to routinely identify families at risk for problems in home care in their clinical practice and work with families to develop strategies to prevent problems
Appendix: References• Bedell S, Jabbour S, Goldberg R, et. al., Arch Intern Med 2000 160 (14): 2129-
2134• Field T, Mazor K, Briesacher B, KR KD, Gurwitz J. Adverse Drug Events Resulting
from Patient Errors Among Older Adults. Journal of the American Geriatrics Society. 2007;55:271-276
• Fletcher SW, Fletcher RH, Thomas DC, Hamann C. Patients' Understanding of Prescribed Drugs. Journal of Community Health. 1979;4(3):183-189.
• McMahon SR, et al. Pediatrics 1997; 100(3 Pt 1): 330-3.• Walsh KE, Stille CJ, Mazor KM, Gurwitz JH. Using home visits to understand
medication errors in children. Vol. 4. Technology and Medication Safety: Agency for Healthcare Research and Quality; August 2000
• Walsh K, Mazor K, Stille C, et. al., Arch Dis Child in press• Weingart S, Gandhi T, Seger, et. al., Arch Int Med 2005 165: 234-240
Appendix: Health Literacy, Primary Language, and Home Medication Errors References
• Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. Jan 2003;111(1):6-14
• Moon RY, Cheng TL, Patel KM, Baumhaft K, Scheidt PC. Parental literacy level and understanding of medical information. Pediatrics. Aug 1998;102(2):e25.
• Yin H, Wolf M, Dreyer B, Sanders L, Parker R. Evaluation of consistency of dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010;304(23):2595-2602.
• Yin HS, Dreyer BP, Foltin G, van Schaick L, Mendelsohn AL. Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambul Pediatr. Jul-Aug 2007;7(4):292-298.