When it comes to administering medications for children at home, a significant burden of responsibility falls on the parents or the patients themselves.1 Medication administration errors have been documented to occur among children.2 Previous studies acknowledged that more than 40% of parents and caregivers make dosing errors in an outpatient setting.3 4
Failure to administer medication correctly can result in adverse drug events and poor clinical outcomes in patients.5
The causes of medication management problems at home are multifactorial and potentially depend on several factors.2 Therefore, to improve medication administration by parents and patients, an initial assessment of current problems should be performed and identified problems. factors that may contribute to this problem.
Previous studies have recognized potential factors that can contribute to medication administration errors in children, but there have been no studies that record both the types and risk factors that can contribute to problems in medication administration by the caregiver, as well as young people.6 7 According to the European Health Literacy Survey, carried out in eight different countries, the prevalence of low level of health knowledge varies from 29% to 62%.8 9
Due to this, the high prevalence of low levels of health literacy and its possible association with medication administration problems among children. This review aimed to identify studies that highlighted medication administration problems experienced by parents and children, and also analyzed the aspect of health literacy using a tool to assess it.
In this systematic review, common medication administration problems that occur at home were highlighted, as well as possible causes and risk factors other than health literacy that could contribute to medication administration errors.
| Methods |
This review was conducted in accordance with the Cochrane Handbook for Systematic Reviews, and the Preferred Reporting Items for Reviews and Meta-Analyses (PRISMA) guidelines for reporting were followed. 10 11 The review protocol is registered in PROSPERO (ID: CRD42018091590).
> Patient and public participation
There were no patients or public involved in the design, conduct, reporting or dissemination of this review.
> Eligibility criteria
Studies were eligible for inclusion if they were related to medication administration errors among children and adolescents between the ages of 0 to 18 years according to the WHO definition of population age group. This includes studies reporting medication-related problems outside of the clinical setting; where the parent or child is responsible for administering or taking the medication.
Studies must have assessed participants’ health literacy levels using a validated health literacy assessment tool. Any study that analyzed only the educational levels of the participants without assessing knowledge levels was excluded. There were no restrictions on publication date, and only studies from articles in English were included.
> Search strategy
The search strategy was initially designed by the research team and verified by an information specialist using the Population, Intervention, Comparison and Results model. The reviewer (DTD) systematically searched PubMed, Scopus, Web of Science, Cochrane Library, OpenGrey, NHS Digital Health Office for National Statistics, BBC News, Bielefeld Academic search engine, the Online Electronic Thesis Service through Web of Science for database initiation studies through September 2020.
Summary search terms include a comprehensive list of synonyms and multiple Boolean operators related to: (1) pediatric (2) medication error including dosing error, medication administration error, medication safety and medication optimization and (3) health knowledge. DTD then additionally performed reference tracking of all included studies to identify any potential studies to be included in the review.
> Selection of studies
Two reviewers (DTD, ZBS) independently assessed each study for eligibility to reduce bias by including the above criteria. The titles and/or abstracts of all identified studies and full manuscripts that appeared potentially relevant were reviewed independently.
> Data extraction and synthesis process
Two reviewers (DTD and ZBS) independently extracted data using a standardized predefined spreadsheet. Inconsistencies in extracted data were resolved by consensus discussion by a third reviewer (CH), if necessary. The results were synthesized and summarized according to analytical themes. The research team opted for thematic analysis as it is known for its flexibility and ability to identify patterns of meaningful information within the data.12
> Quality evaluation
The quality of included articles was independently assessed by two reviewers (DTD, ZBS) using Critical Appraisal Skills Program checklists.13, 14 Discrepancies were resolved through discussion and consensus.
| Results |
A total of 672 citations were retrieved from the database and other searches. After screening titles and abstracts, 38 full-text publications were obtained and evaluated for suitability. Of which, 14 met the inclusion criteria and were included in the analysis.15-28
Most of the included studies were published in the last 12 years. All studies (n = 14) took place in the United States.
Overall, 11 studies recruited parents or caregivers of children aged 30 days to less than 9 years, 2 studies recruited parents without limitations on child age, and 1 study recruited only women of childbearing age. Most studies (n = 13) reported the ethnic composition of their recruited sample and were largely Hispanic or Black African American parents or caregivers. Only one study recruited exclusively women of white ethnic origin.22
> Quality evaluation
All identified studies were included in the final synthesis with greater emphasis on higher quality studies.
> Summary of results
Data from all 14 studies were analyzed and three analytical themes emerged from the analysis.
> Types and causes of medication administration errors among children by parents or children outside of a clinical setting
Eight of the included studies indicated that pediatric dosing errors are among the most common medication errors made by parents.15 18-21 23 24 26 Among these studies, two randomized trials identified that overdose errors are most common among parents.23 24 While other cross-sectional studies focusing on parents with children on a short-course prescribed medication reported that the majority of parents measured below the prescribed dose.15
A study by Morrison et al20 reported that parents who made underdosing errors made more dosing errors and frequency errors compared to those who had an overdose error.
Of the included studies, it was noted that the magnitude and frequency of dosing errors by parents were influenced by two factors: the measurement tool used by the parents and the volume of the dose (quantity). In one study, parents reported that a non-standardized kitchen spoon was their primary dosing tool.17 Two studies reported that errors were more common with measuring cups than with syringes, particularly with small dose volumes (quantities).21 24
In a cross-sectional study conducted in the US, 66% of parents considered oral syringes to be the best tool for dosing accuracy, while 23.5% believed cups were best; However, 10.1% believed that the measuring spoon, measuring spoon, kitchen teaspoon, and droppers were best.27
Another study reported that the largest dosing errors (>40% deviation from the recommended dose) were for parents using cups with printed markings and engraved markings; This is believed to be due to confusion over teaspoon versus tablespoon instructions, assumptions that the cup is the unit of measurement and the full cup is the dose.16
The labels and units of the prescribed medication were contributing factors to dosing errors.24 Parents had significant dosing errors when the units found on the medication bottle label were not similar to the units used in the dosing tool .24 Parents who used teaspoon/tablespoon units are likely to use a non-standardized dosing instrument and make errors when measuring the prescribed and intended dose.19
The final potential factor was the type of instructions provided. For liquid medication, fewer errors occurred among parents who received text instructions plus pictogram instructions (43.9%) compared to text-only instructions (59.0%) and this group was also less likely to make errors of overdose. 26
Parents who received standard medication counseling were 47.8% more likely to make dosing errors compared to parents who received pictogram instruction (5.4%). 25
> Factors related to patients or caregivers and medication errors
Health knowledge
Caregivers’ health knowledge was assessed in the studies; six conducted additional analyzes of their influence on dosing accuracy and other cofactors related to medication errors. Yin et al17 reported that caregivers with insufficient health literacy were more likely to use a non-standardized dosing instrument and lacked knowledge of weight dosing compared to caregivers with adequate health literacy. Another study by Yin et al16 found a significant association between health knowledge and dosing errors when using measuring cups and spoons.
In an adjusted analysis by Williams et al., 27 found that there was a strong association between health literacy levels and preference for measuring tools in particular cups, parents with limited knowledge reported that measuring cups were the preferred tool. most of the time (aOR = 2.4).
Using a teaspoon/tablespoon was associated with errors in intended dosage for those with low health literacy, but not in those with adequate health literacy.19 Harris et al21 identified that parents with limited health literacy and limited proficiency of English (DLI) made the most dosing errors. Similarly, Samuels-Kalow et al18 revealed that parents with inadequate and marginal health knowledge made dosing errors, but the sample size of this group was small compared to the group with adequate health knowledge.
Language
The association between health literacy and lack of knowledge of weight-based dosing varies by caregiver speech. For English-speaking caregivers, 88.6% of caregivers with inadequate or marginal health literacy had no awareness of weight dosing compared to 54.1% of caregivers with adequate health literacy.17
Yin et al26 found that there was no significant relationship between dosing error and DLI. However, there were some differences in measurement errors per teaspoon by language.19
Understanding and remembering instructions in relation to the sociodemographic status of parents
Yin et al25 reported that low sociodemographic parents who were prescribed a daily dose and who received simple language, pictogram instructions, were less likely to make errors in dosing frequency and accuracy compared to the group control who received standard medication advice (0% vs 15.1%).
Participants among the interventional group were less likely to incorrectly report medication preparation related to shaking the medication before administration for both daily doses (10.9% vs 28.3%, p = 0.04) and medication as appropriate. necessary (21.5% vs 43.0%). 25
Participants in the intervention group were less likely to use a non-standardized method of measurement compared to parents in the standard group (daily dose: 93.5% vs. 71.7%; as needed: 93.7% vs. 74 .7%).25
Torres et al., 28 in a cross-sectional study that analyzed data from a randomized control study, assessed parental preference and perceptions rather than units of measurement. It found that more than 80% of parents perceived that a change to milliliters in the instructions would be easy compared to 14% who found it somewhat difficult and 4.1% very difficult.
> Interventions aimed at reducing medication administration errors that occur in children outside of a clinical setting
Sociodemographic factors of parents
Four studies suggested that parental sociodemographic risk factors should be taken into account when designing an intervention aimed at preventing medication administration errors. 16 17 21 26
These factors include health knowledge and language. Kalow et al suggested that efforts to streamline interpreter services should be ongoing as well, to have a more formalized approach in place to elucidate the patient’s preferred language for communication.18
Advice and training
Three studies suggested that interim dosing advice (showing the patient how to prepare the dose) in combination with verbal advice could be associated with fewer dosing errors.15 17 23
A study by Yin et al15 indicated that errors occur in different counseling approaches, and have recommended developing new strategies to ensure that parents understand medication instructions, as well as the need for more research to identify the best counseling strategies and how incorporate them into clinical practice. Yin et al24 suggested the need for intensive teaching, training and counseling programs that can be adapted to different levels of parental health literacy.
Tools, labels and instructions
Yin et al suggested a promising strategy that could potentially help reduce errors in pediatric dosing, to match the dosing tool to the prescribed dose volume and move toward more simplified numerical markings on measurement tools, as well as to pass just milliliters. 24 26 28 Wallace et al22 indicated in their study that some parents prefer instructions with explicit dosing intervals with the exact time and dose to be specified on the label.
Harris et al21 suggested improving the availability of language-concordant labels that could be adapted to different levels of health literacy. Three studies in this review strongly suggested the importance of using pictographic dosing instructions and how it could be a positive aid in reducing dosing errors in pediatrics. 23 25 26 Most parents would be comfortable with dosing instructions in milliliters alone.
| Discussion |
The results of this study suggest that parents appear to make a number of medication errors, especially with liquid medications as documented by previous studies that were also conducted in the US, such as studies in this review.2 4 23 25 The majority of included studies indicated that dosing errors were among the most common medication errors made by parents, which is consistent with another study that was conducted on Spanish-speaking Latino parents.15 19 21 25 29
This review identified possible causality behind parental dosing errors in addition to the effect of health knowledge; These errors could be related to: the dose volume prescribed, the measurement tools used, the units used on the labels, and the instructions provided.
Although standardized measurement tools are often dispensed with prescribed liquid medications in the United Kingdom, this review identified that studies published in the United States indicated that parents still use non-standardized liquid dosing tools as their primary measurement tool; this has previously been linked to medication administration errors by both Yaffe et al and McMahon et al.30 31
The review found that matching medication labels to the closest measuring tool size, especially for labels with milliliters only, could be associated with a reduction in dosing error rates in administration by parents, as well as a decrease in the likelihood that parents will use non-standardized measurement methods suggested by other research.19 32
The review showed that the use of simple pictogram medication instructions with explicit dosing intervals could reduce dosing errors by parents. This finding was consistent with previous existing data from Southern and West Africa as well as the USA regarding the use of pictographic illustrations as a support tool to help parents administer medications to their children correctly. 33-41
This could potentially benefit parents and caregivers with limited or low levels of health literacy. The authors’ findings are consistent with previous US studies investigating the link between sociodemographic characteristics of adults, particularly health literacy, and medication administration problems.42-45
Four studies explicitly highlighted that sociodemographic factors, such as health literacy and language, should be incorporated into any future interventions that aim to reduce parental medication administration and dosing errors.
The results of the review highlighted several interventions to help parents and patients potentially reduce medication administration errors at home. This includes the use of simple language combined with the use of the provided dosing tool, as well as incorporating pictographic instructions which were consistent in four of the included studies.15 23 25 26 Simple pictographic instructions significantly improve dosing accuracy and administration of medications to children especially for those parents with insufficient knowledge about health.25 26
This study emphasized potential areas that could be incorporated into real-world practice to help reduce medication administration errors made by parents/caregivers and patients. Potential strategies include personalized training that accommodates different levels of health literacy and languages as well as the ability to match the dosing tool to the prescribed volume along with the use of milliliter units.
This review is subject to several limitations. There were two major limitations of the study. First, they only included studies in English, so there may be publication bias and studies not conducted in English related to this topic may have been lost. Second, they only included studies that assessed knowledge using a validated tool. This led to only US studies being included.
Knowledge is a problem around the world, but of greatest importance in low- and middle-income countries. Future reviews should include other studies expanding the search strategy.
Additionally, although the study aimed to include medication management challenges for younger people aged 16 to 18 years, none were included as they did not meet the eligibility criteria for this review. Future research is needed where younger people aged 16 to 18 are included as participants.
Furthermore, the generalizability of the study results might be low; this is because most of the studies were conducted in the US and emerged from the same research group as Yin et al. This research group has highlighted several limitations in their studies, such as the use of hypothetical scenarios that may not be an accurate reflection of how parents measure dosage at home. 16 23 24 26
For some randomized trial studies in this review, it was difficult for the research team to maintain blindness as some of the participants revealed their assigned group, while for cross-sectional studies, no conclusion can be drawn about the causes.17 19 25
Finally, the publication date of one of the studies was 13 years old, 17 which would not take into account the changes that have occurred in terms of interventions that would vary at local, national and international levels. However, this review highlights to date that non-standard dosing is still performed due to parental preference, based on recent evidence from 2018.28
| Conclusions |
The findings suggest that to optimize parents’ medication use, more work is needed to address the nature of these problems at home. Counseling, medication administration instructions, and measurement tools are some of the areas, in addition to the sociodemographic characteristics of parents and youth, that are among the factors to consider when designing any possible future interventions aimed at reducing the Medication errors among children and young people at home.
