Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

Language barriers between patients and providers is a potential contributor to adverse events. Based on a cohort of 1,666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspeciality patients 17 years and younger, this study examined the association between parents with limited comfort with English (LCE) and adverse events in hospitalized children. Compared with children of parents who expressed comfort or proficiency with English, children of parents who expressed LCE had significantly higher odds of experiencing an adverse event, including preventable events. Future research should focus on strategies to improve communication and safety for this vulnerable group of children.

Health literacy is the capacity of patients and their families to process and understand health information including educational materials and patient instructions. This editorial discusses the importance of heath literacy in promoting patient safety, particularly around discharge and medication instructions. 

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

Inaccurate dosing of liquid medications for pediatric patients is known to contribute to medication errors. In this randomized controlled trial, parents of children younger than 9 were able to demonstrate a correct liquid medication dose when they received a dosing tool, such as a syringe, that corresponded more closely to the prescribed medication volume. Directions that include a picture were more likely to lead to accurate dosing compared to text-only instructions. This study adds to prior research demonstrating the need for literacy-friendly medication instructions, especially for dosing of liquid medications to children. Two of the coauthors, Michael S. Wolf and Stacy C. Bailey, described the implications of limited health literacy on patient safety in a past PSNet perspective.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

Non–English-speaking patients face particular challenges associated with health literacy. This commentary highlights how pharmacists have a greater role in health care decisions in Latin American nations than in the United States. The authors describe why inconsistent and incomplete application of policies in US pharmacies contributes to risks and suggest prescription and medication delivery processes be altered to address this weakness.

Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.

This study found that parents given pediatric medication instructions using milliliter-only units made half as many dosing errors as parents that used teaspoon or tablespoon units. Non-english speakers and those with low health literacy were most vulnerable to dosing errors. The authors advocate for moving to a milliliter-only standard to reduce confusion and improve medication safety for children.

Errors are very common when parents administer medications to their children. According to this study, counseling by emergency department staff that included demonstration with an actual dosing instrument was associated with a lower incidence of errors. However, counseling alone did not seem to improve safety.

… for action to promote patient safety. A past AHRQ WebM&M commentary discussed a pediatric dosing error involving OTC …

Efforts to develop health literacy interventions are one strategy to improve medication safety. In pediatric populations, the need for parents to understand liquid medication dosing poses additional risks. This study evaluated the role of dosing instrument type (e.g., cups, droppers, syringes) on parents' medication administration errors. Investigators found that dosing accuracy was lowest when using cups, and that cups were also associated with the largest deviations in dosing errors administered. Limited health literacy was also associated with parents' dosing errors. A previous WebM&M commentary discusses safety problems caused by low health literacy.  Accompanying this article [see link below] is an Advice for Patients educational page that highlights pearls for medication safety in children.

This survey revealed that many adults do not understand instructions for common liquid prescription medications, potentially increasing the risk of serious medication errors. Prior research in this field has demonstrated that low health literacy is an important predictor of misunderstanding prescription instructions. Concerningly, in this study nearly 1 in 5 patients who had adequate health literacy could not correctly interpret the instructions, and patients with marginal or low health literacy were at even greater risk. A previous WebM&M commentary discusses safety problems caused by low health literacy. 

This article describes how health literacy affects care for pediatric patients with chronic illnesses as well as efforts to promote safe care in this population.

The US Food and Drug Administration discourages the use of over-the-counter cold medications in children younger than 2 years. Despite this, most parents in this study thought such medications were entirely appropriate for their infants, and appeared to be unduly influenced by the product labeling and graphics. Prior research has identified low health literacy as a prominent risk factor for misinterpreting prescription drug labels. This study also found that limited numeracy (the ability to apply arithmetic operations to everyday tasks) was a risk factor for incorrectly interpreting the product labeling. A prior trial used pictorial displays to explain medication dosing in children and resulted in fewer errors and improved adherence.

This study incorporated the use of a pictogram in medication counseling and showed that it decreased dosing errors and improved adherence. The strategy described builds on existing efforts to develop health literacy interventions for improving medication safety.