HoMeS: Home Medication Support
- 1. 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
- 2. Clinical Cases • 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
- 3. 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
- 4. Why is support for home care important • 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
- 5. Definitions • 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 Medication errors Adverse drug events Error Error Adverse without with event adverse adverse without event event error
- 6. 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 children on 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.
- 7. Comparison of pediatric and adult medication errors found in chart review at 4 Cancer Research Network sites, N=1379 clinic visits sites 16 14.5 Rate of errors per 100 clinic visits 14 12 10 Pediatrics 8 5.8 Adults 6 4.3 4 2 0.7 0 Clinic Home Walsh KE, Dodd KS, Seetheraman K, et al. Journal of Clinical Oncology 2009;6:891-896.
- 8. Home visit methods Obtain diagnoses and medication list from medical record Home Visit: Direct Observation* Identification of Strategies to Review of Medications Prevent Errors Parent Interview Physician Review of Possible Errors * 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.
- 9. Errors found in 60% of homes during home visits Sickle Cell Epilepsy Cancer (N=25) (N=28) (N=27) Number of medications 119 154 290 Number errors 41 28 52 Rate error per 100 medications 34.4 18.1 17.9 (Confidence Interval) (25.9-42.9) (11-25.2) (12.4-23.7) With injury 6.7 0.7 1.4 No injury but potentially dangerous 17.6 8.4 11.0 Trivial 10.1 9.1 5.5 Overall, 60% of children had a medication error found on a home visit
- 10. Parent use of support tools associated with significantly less errors No supports Supports At least one 19 14 error at home No error 1 18 * X2=13.9 (p=0.0002)
- 11. 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
- 12. Risk factors for home medication error • More medications = more mistakes 1 • Regimens that fit with a normal routine work better 2 – 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 it 3 1. Holdsworth, Arch Pediatr Adolesc Med. 2003 2. 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
- 13. More medications = more mistakes
- 14. More complex regimens are more prone to error
- 15. Communication problems leading to error • Adult patients do not tell their doctors about home changes in dose, missed doses, side effects 1,2,3 • 60% of children with chronic conditions are given medicine by multiple difference caregivers 4 – 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
- 16. Prevention: Have 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
- 17. Prevention of measurement error: Syringe 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 would measure medicine at home. Group How they did Prescription and verbal 2. 37% correct dose instructions Prescription with syringe 4. 83% correct and demonstration Prescription, syringe with 5. 100% correct a line marked, and demonstration McMahon SR, et al. Pediatrics 1997; 100(3 Pt 1): 330-3.
- 18. Prevention: ALWAYS… • Say what the medication is for • Say how to give the medicine • Ask if there are any questions
- 19. Prevention: Doctor-parent brief communication guide Problem Recommendation Acetaminophen or ibuprofen under Review dose at every visit dosing Failure to change doses or fill Ask parent to bring in all medications; prescriptions ask about dose, timing, preparation Problems giving medications at Ask about problems giving medication: home general problems/refusals? vomiting? missed doses?
- 20. Prevention: Doctor-parent brief communication guide Problem Recommendation Miscommunication between in home •“Who gives medicines at home?” caregivers (parents, parent and •multiple people? babysitter, others) •Do parents have a: •System for communicating about changes •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
- 21. Prevention: Doctor-parent brief communication guide • Please identify 3-5 patients in your practice who are at risk for home medication errors • Please print the Link to Brief Communication Guide for doctors communication guide and try it with them
- 22. 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
- 23. Contact Kathleen Walsh at WalshK02@ummhc.org with any questions
- 24. 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
- 25. 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.
Editor's Notes
- #8: 117 pediatric visits with 913 medications 7.7% had a serious medication error 4 pediatric errors reached patient and resulted in injury 1259 adult patient visits with 10,995 medications 4.4% had a serious medication error 11 adult errors reached patient and resulted in injury
- #18: In the outpatient setting, it is the parents, not nurses, administering medications. It has been shown that 15% English speaking adults can not read and interpret bottle label. The home Home tsp varies in size from <2.5 to 5.5 mL In a nice study in an urban clinic, McMahon randomized 90 English and Spanish speaking parents of children under 4yo diagnosed with OM to three groups: group one got a Prescription and verbal instructions, group 2 got a Prescription with syringe and demonstration of dose, and group 3 got Prescription, syringe with a line marked , and demonstration. Parents picked up the med from pharmacy and returned to demonstrate the dose. Results… Authors conclude that parents can accurately dose liquid medications