Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study

Yin, H. Shonna; Parker, Ruth M.; Sanders, Lee; Mendelsohn, Alan L.; Dreyer, Benard P.; Bailey, Stacy Cooper; Patel, Deesha A.; Jimenez, Jessica J.; Kim, Kwang Youn; Jacobson, Kara L.; Smith, Michelle; Hedlund, Laurie; Meyers, Nicole; McFadden, Terri; Wolf, Michael S.

doi:10.1542/peds.2016-3237

Cited by 63 publications

(73 citation statements)

References 30 publications

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“…This requires that all caregivers are adequately trained on how to appropriately administer the medication, despite the fact that only the parent might have been instructed on medication administration by a physician or other medical provider. In addition, use of over-the-counter medications occurs frequently, parents often fail to use standard dosing instruments, and commonly used prescribing terms such as ‘teaspoon’ and ‘tablespoon’ are often confused 24…”

Section: Medication Administrationmentioning

confidence: 99%

“…A major focus of this initiative and of paediatric medication safety research is on reducing MAEs through use of standard medication labels and dosing devices. Research has shown that provision of dosing tools that more closely match prescribed dose volumes may be particularly effective for reducing dosing administration errors 24. Because low health literacy is a major risk factor for MAEs, increasing use of pictograms has been promoted.…”

Section: Medication Administrationmentioning

confidence: 99%

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What is new in paediatric medication safety?

Kahn

Abramson

2018

Arch Dis Child

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Medication-related errors are among the most common medical errors, and studies have shown that the paediatric population is particularly vulnerable. Errors can occur during any step in the medication process. This review article seeks to highlight new advancements in the field of paediatric medication safety at each stage of the medication process, from ordering and transcribing to medication dispensing and administration. We will focus on interventions that are increasingly widely used, such as computerised provider order entry with clinical decision support, barcoding technologies and safe medication administration through technologies pumps (SMART pumps), as well as innovative mobile application devices and workflow management systems that are being piloted at single institutions. By highlighting what is new in paediatric medication safety, as well as the gaps that remain, we hope to continue to foster focus on this critically important area in order to create the safest possible environment for children.

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Section: Medication Administrationmentioning

confidence: 99%

Section: Medication Administrationmentioning

confidence: 99%

What is new in paediatric medication safety?

Kahn

Abramson

2018

Arch Dis Child

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“…Another SAFE Rx for Kids experiment investigated additional strategies to reduce dosing errors, with findings published in 2017. 4 Text-plus-pictographic dosing instructions were associated with a twofold reduction in large overdosing errors (>2-fold errors) compared with text-only instructions. Fewer errors were seen when parents measured with tools with a volume capacity more closely matched to the prescribed dose volume; a tool that is much larger than necessary allows room for excess medication, whereas a tool that is smaller than a prescribed dose necessitates the measurement of >1 instrument full.…”

Section: What's Newmentioning

confidence: 93%

Identifying and Advancing Best Practices for the Labeling and Dosing of Pediatric Liquid Medications: Progress and Challenges

Yin

Vuong

Parker

et al. 2019

Academic Pediatrics

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“…61 Liquid dosing errors can be addressed with in-office videos, effective measurement devices, teach-back and show-back counseling techniques, and picturebased handouts. 62 Evidence-based clinical practice guidelines can direct care decisions both toward wanted and away from unwanted actions, resulting in reduced opportunities for harm and in improved outcomes. 57 Other safety goals, such as the recognition of a change in a patient's status or encouraging patient and family involvement in the patient's care, require a composite of changes to health care systems and expectations of both providers and consumers.…”

Section: Patient Safety Strategiesmentioning

confidence: 99%

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

et al. 2019

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Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care." BACKGROUND INFORMATION Patient safety is defined as the prevention of harm to patients. 1 Although patient safety is only 1 of the 6 domains of quality of care defined by the National Academy of Medicine (formerly the Institute of Medicine [IOM]), 2 it is undoubtedly one of the most important. There are real and growing concerns regarding pediatric errors and harms reported related to specific populations, such as with the use of temporary names in newborn care, 3 as well as issues spanning all populations, such as diagnostic errors in ambulatory and hospital settings 4 and information technology errors in prescribing. 5 Pediatricians in all practice settings can help champion the

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Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study

Abstract: Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.

Cited by 63 publications

References 30 publications

What is new in paediatric medication safety?

What is new in paediatric medication safety?

Identifying and Advancing Best Practices for the Labeling and Dosing of Pediatric Liquid Medications: Progress and Challenges

Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care

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