Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.

Prior research has shown that patients with limited health literacy are at increased risk for misunderstanding the appropriate dosing of acetaminophen, a commonly used nonprescription medication that can cause acute liver failure after an overdose. In this study, researchers examined the risk of nonprescription acetaminophen misuse among 500 English-speaking patients across 4 outpatient clinics. They found that 39% of participants had limited health literacy and 54% had low visual acuity. Both reduced visual acuity and lower health literacy were independent risk factors for dosing errors and for insufficient understanding regarding the simultaneous use of multiple acetaminophen-containing products. An AHRQ Literacy Toolkit is available that provides a business case for interventions, educational tools, and guides for engaging patients in health literacy discussions. A previous WebM&M commentary discussed an incident involving confusion with acetaminophen dosing.

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.

Errors in patient use of medications can lead to adverse drug events. This randomized trial demonstrated that a patient-centered label strategy improved instruction comprehension and adherence for patients with limited literacy and complex medication regimens.

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.

In this cluster randomized trial among 47 primary care practices, prompting clinicians to enter justifications for prescribing antibiotics in patients with antibiotic-inappropriate diagnoses or providing peer comparisons through emails decreased mean antibiotic prescribing rates compared to controls. Antibiotics are a significant source of medical care overuse and inappropriate prescriptions can lead to avoidable harms.

Medication errors are likely the most common patient safety threat in ambulatory care, and this survey of primary care patients revealed many issues that are putting patients at risk for adverse drug events. Patients assumed that their primary care doctor was aware of all their medications, including those prescribed by other physicians, despite evidence documenting poor information sharing between community physicians. Although prior studies show that pharmacist counseling may reduce medication error rates in outpatients, only a minority of patients receiving new prescriptions reported receiving counseling (from a physician or pharmacist) regarding potential adverse effects. The discordance between patient assumptions and physician knowledge about medication regimens points to a need for greater patient engagement in medication reconciliation efforts.

Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading cause of acute liver failure in the United States, with the majority of cases being unintentional. Prior studies have shown that patients with limited health literacy frequently misunderstand dosing instructions for prescription medications, and this study examined the frequency with which adult patients misunderstood dosing instructions for acetaminophen. Patients were provided with actual bottles of medications and asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under these simulated conditions, nearly half the patients would have overdosed either by exceeding the recommended daily dose of acetaminophen or by combining two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by incorrect dosing of acetaminophen.

Limited health literacy has been linked to poor comprehension of written instructions. This study found that spoken instructions were also frequently misunderstood by patients with poor health literacy.

… victory after an avoidable error. … Salanitro AH, Osborn CY, Schnipper JL, et al. Effect of patient- and …

This study found that patients, particularly those with limited health literacy, would benefit from clearer understanding, organization, and simplification of their medication regimens.

In November 2009, the US Food and Drug Administration (FDA) released a voluntary set of recommendations around the safety of over-the-counter (OTC) medications, particularly for children. This study examined the prevalence of inconsistent dosing directions and measuring devices among 200 top-selling pediatric liquid OTC medications. Investigators discovered an alarming 99% rate of inconsistency between medication dosing directions and the markings on the measuring device. Furthermore, the use of milliliter, teaspoon, and tablespoon units were also highly variable as was nonstandard abbreviations for milliliter. The authors advocate for three specific recommendations based on their findings: (i) ensure standardized measuring devices in all liquid packaging, (ii) ensure consistency between label dosing instructions and markings on measuring devices, and (iii) choose standard measurement units and abbreviations. A related editorial and news piece [see links below] discuss the implications of this study and the growing need for action to promote patient safety. A past AHRQ WebM&M commentary discussed a pediatric dosing error involving OTC acetaminophen.

In this multicenter study, patients with limited health literacy consistently reported dissatisfaction with the communication they received from health care providers.

The landmark Institute of Medicine report on patient safety categorized inappropriate plans of care as a medical error. This broad classification encompassed decision-making errors by clinicians that included diagnostic errors but also the notion of contextual errors. The latter are those that occur because of inattention to patient context such as environment, behavior, economic situation, or access to care and social support. This study used unannounced standardized patients who acted out four clinical scenarios presenting with biomedical and contextual complicating factors. Attending physicians probed fewer contextual red flags than biomedical ones and provided error-free plans of care in 73% of the uncomplicated encounters, 22% of the contextually complicated encounters, and only 9% of the combined biomedically and contextually complicated encounters. The authors advocate for greater attention and performance metrics to assess how well providers deliver individualized patient care plans based on probed contextual factors.

This AHRQ-funded study found that physicians usually chose appropriate reasons for excluding patients from inclusion in quality measurement programs.

Medication reconciliation discrepancies—differences between the medical record and patient self-report of their antihypertensive medications—occurred in 75% of patients in this study. These discrepancies were associated with a higher likelihood of uncontrolled hypertension. Prior research has addressed the difficult question of medication reconciliation in ambulatory care.

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.