More than 80% of parents make measurement errors with their children's medications, of which a third were large errors, suggesting the need for tools to better match prescribed dose volumes in order to prevent accidental overdoses, reported New York University researchers.
According to results from a randomised trial involving nearly 500 parents, a large majority (83.5%) made at least one dosing error, report Dr H Shonna Yin of New York Univeristy Langone Medical Centre, and colleagues. Almost one third made at least one large error, the researchers found. Among all errors, 12% involved an overdose.
But when parents had dosing implements closely matched to prescribed dose volumes, the error rate was much lower.
"Giving a parent a dosing tool, like an oral syringe, that is the right size, can have a big impact on whether a parent will dose a medication accurately," Yin said. "If the tool is too large, parents are more likely to overdose. If the tool is too small to allow the parent to measure the full dose with a single measurement, then parents will need to use math skills to figure out how to accurately measure more than one instrument-full, which increases the likelihood of a dosing error," she explained.
Yin and colleagues recruited 491 parents from 20 February, 2015, to 23 July, 2015 from three pediatrics outpatient clinics in New York City, Atlanta, and Atherton, California. English- and Spanish-speaking parents with children ≤8 years old were randomly assigned to one of four groups: text and pictogram instructions on the label, "mL"-only label and tool; text and pictogram instructions, "mL/tsp" label and tool; text-only instructions, "mL"-only label and tool; and text-only instructions "mL/tsp" label and tool.
Dosing error was determined by the weight of the measured dose compared with a reference weight (5-mL dose defined as the average weight of 5 mL measured by 10 pediatricians using an oral syringe). If the measured amount was different from the amount listed on the label by >20%, the parent was considered to have made a clinically meaningful dosing error.
The researchers found that parents who received text and pictogram dosing instructions with "mL"-only labels and tools had decreased odds of making a dosing error compared with those who received "mL/tsp" labels and tools with or without pictographic dosing instructions.
There were more errors with the 2- and 7.5-mL doses tested compared with the 10-mL dose – 2 mL versus 10 mL: aOR 3.7 (95% CI 3.1–4.4) and 7.5 mL versus 10 mL: aOR 1.4 (95% 1.2–1.6).
For the 2-mL dose, the fewest errors were seen with the 5-mL syringe — 5- versus 10-mL syringe aOR: 0.3 (95% CI 0.2–0.4) and cup versus 10-mL syringe: aOR 7.5 (95% CI 5.7–10.0).
For the 7.5-mL dose, the fewest errors were with the 10-mL syringe — 5- versus 10-mL syringe: aOR 4.0 (95% CI 3.0–5.4) and cup versus 10-mL syringe: aOR 2.1 (95% CI 1.5–2.9).
Millilitre/teaspoon was linked to more errors than millilitre-only, aOR 1.3 (95% CI 1.05–1.6), noted the researchers.
"This study supports system-wide changes in the design of medication labels and provision of dosing tools that would help reduce medication errors in children," Yin said. She continued that the development of standards around the provision of dosing tools, by pharmacies and manufacturers of over-the-counter and prescription medications, along with increased awareness by providers and pharmacies, could help to better ensure that parents receive optimal dosing tools.
Looking forward, the researchers called for a comprehensive labelling and dosing strategy for pediatric liquid medications that they are now testing in a "real world" randomised trial.
Study limitations included the use of a hypothetical dosing scheme which might not have accurately reflected how parents dose at home, as well as a limited number of dosing tools, capacities, and volumes.
Abstract
Background and Objectives: Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes.
Methods: This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children ≤8 years old were randomly assigned to 1 of 4 groups and given labels and dosing tools that varied in label instruction format (text and pictogram, or text only) and units (milliliter-only ["mL"] or milliliter/teaspoon ["mL/tsp"]). Each parent measured 9 doses of liquid medication (3 amounts [2, 7.5, and 10 mL] and 3 tools [1 cup, 2 syringes (5- and 10-mL capacities)]) in random order. The primary outcome was dosing error (>20% deviation), and large error (>2× dose).
Results: We found that 83.5% of parents made ≥1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made ≥1 large error (>2× dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2–0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7–10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0–5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5–2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05–1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1–3.3], aOR = 2.5 [1.4–4.6], respectively).
Conclusions: Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.
Authors
H Shonna Yin, Ruth M Parker, Lee M Sanders, Alan Mendelsohn, Benard P Dreyer, Stacy Cooper Bailey, Deesha A Patel, Jessica J Jimenez, Kwang-Youn A Kim, Kara Jacobson, Michelle CJ Smith, Laurie Hedlund, Nicole Meyers, Terri McFadden, Michael S Wolf
[link url="http://www.medpagetoday.com/pediatrics/parenting/66274"]MedPage Today report[/link]
[link url="http://pediatrics.aappublications.org/content/early/2017/06/23/peds.2016-3237?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token"]Pediatrics abstract[/link]