Teachable Moments to Prevent Medication Errors

When we consider education, in the medical arena, we often neglect to consider one of the most vital and important beneficiaries of the teaching endeavor: patients and their families. We have previously discussed this in past a Newsletter (We All Teach – February 2013).

Each patient encounter is filled with a multitude of “teachable moments.” Most of us are eager to take the opportunity to advocate of the use of helmets when we are evaluating the patient who fell while skateboarding and only suffered a forearm fracture. We are quick to express the importance of ensuring dangerous substances are adequately locked away from children while we consol the family who found their infant sitting in spilled bleach. Injury prevention comes naturally to many of us who see the consequences of those injuries, but let us not forget one area that we should all consider a teachable moment: medication administration. Medication Errors are a significant problem that a little preemptive education can help avoid.


Giving Medicine is Tricky

  • Medication errors are a common cause of adverse events and are more often seen in pediatric patients than adults.
    • Kids’ various sizes (both in weight and body surface area) and metabolic rates create challenges.
    • The fact many pediatric medications are liquid creates another challenge.
  • Even the experts are susceptible to error.
    • The chaotic environment of the ED, certainly enhances the chances of error (Leape, 1991).
    • Protective systems can help decrease medication errors in the hospital (Damhoff, 2014).
      • Some examples:
      • Electronic ordering systems
      • Avoiding often confused units of measure
      • Using weight-based dosing
      • Pediatric-specific pharmacy
      • Pharmacist in the ED
    • Still no system is fool-proof and requires vigilance.
  • If the experts are susceptible to error, how can we expect parents and care-givers to get it right?
    • An estimated 71,224 ED visits per year were made for unintentional overdose in children (Schillie, 2009).
    • ~34% were for over-the-counter (OTC) medications
    • ~14% were for medication errors / misuse
  • The odds are stacked against families!
    • Parents may not know the child’s specific and current weight at the time of medication administration.
    • Health Literacy and Numerical Literacy varies greatly amongst all patients and impacts interpretation of medication instructions (Bailey, 2009).
    • OTC medications may exist in various concentrations complicating administration.
    • It has been found that OTC medications often contain variable and inconsistent dosing directions (Yin, 2010).
    • OTC measuring devices have also been found to be inaccurate, inconsistent, and confusing.
    • There are a variety of measuring devices, often not standardized.
    • Measuring cups, syringes, droppers, “teaspoons,” etc.
    • Medicine cups have been shown to be related to a high occurrence of dosing errors (Tanner, 2014).


A Teaspoon Should NOT Be For Medicine

  • Parents who use teaspoon or tablespoon units had TWICE the odds of making an error! (Yin, Pediatrics 2014)
    • While a teaspoon is a unit of measure, it also often confused with the household utensil, which may vary greatly in actual size.
    • Abbreviations can be confusing: “tsp” can be misinterpreted as “tbsp” and vice versa.
  • Advocate for the use of milliliters as the unit of measure.


Educate and Simulate

  • We all know that simulation strategies have benefited our processes of medical education… hands-on helps the memory.
  • Use this strategy for patients and parents as well.
  • The use of both education and demonstration have been found to be more effective at reducing liquid medication dosing errors (Yin, Academic Pediatrics 2014).
  • Establish systems in your ED that encourage this process to help avoid preventable medication errors.
    • Use a oral syringe with milliliter measurements.
    • Discuss the appropriate dose and frequency of the medication.
    • SHOW the family how to fill the syringe to the appropriate dose. Ensure that this is not ambiguous.
    • Have the family teach/show you how they will administer the medication at home.
  • Discharge with clear instructionsillustrating the key points again.


Yin HS1, Dreyer BP2, Moreira HA2, van Schaick L2, Rodriguez L3, Boettger S2, Mendelsohn AL2. Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014 May-Jun;14(3):262-70. PMID: 24767779. [PubMed]

Yin HS1, Dreyer BP2, Ugboaja DC2, Sanchez DC2, Paul IM3, Moreira HA2, Rodriguez L4, Mendelsohn AL2. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014 Aug;134(2):e354-61. PMID: 25022742. [PubMed]

Koumpagioti D1, Varounis C2, Kletsiou E2, Nteli C3, Matziou V4. Evaluation of the medication process in pediatric patients: a meta-analysis. J Pediatr (Rio J). 2014 Jul-Aug;90(4):344-55. PMID: 24726455. [PubMed]

Damhoff HN1, Kuhn RJ2, Baker-Justice SN1. Medication preparation in pediatric emergencies: comparison of a web-based, standard-dose, bar code-enabled system and a traditional approach. J Pediatr Pharmacol Ther. 2014 Jul;19(3):174-81. PMID: 25309147. [PubMed]

Neuspiel DR1, Taylor MM2. Reducing the risk of harm from medication errors in children. Health Serv Insights. 2013 Jun 30;6:47-59. PMID: 25114560. [PubMed]

Tanner S1, Wells M, Scarbecz M, McCann BW Sr. Parents’ understanding of and accuracy in using measuring devices to administer liquid oral pain medication. J Am Dent Assoc. 2014 Feb;145(2):141-9. PMID: 24487605. [PubMed]

Yin HS1, Wolf MS, Dreyer BP, Sanders LM, Parker RM. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010 Dec 15;304(23):2595-602. PMID: 21119074. [PubMed]

Schillie SF1, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009 Sep;37(3):181-7. PMID: 19666156. [PubMed]

Bailey SC1, Pandit AU, Yin S, Federman A, Davis TC, Parker RM, Wolf MS. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009 Nov-Dec;41(10):715-21. PMID: 19882395. [PubMed]

Madlon-Kay DJ1, Mosch FS. Liquid medication dosing errors. J Fam Pract. 2000 Aug;49(8):741-4. PMID: 10947142. [PubMed]

Leape LL1, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377-84. PMID: 1824793. [PubMed]

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