Home Care in Children

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 • Residents will know what difficulties children and families experience in home medication use and will identify child and family risk factors for these difficulties • Residents will develop skills in inquiring about home medication use, identifying difficulties, and working with families to develop systems-based solutions to prevent problems • 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 Adverse event without error Error with adverse event Error without adverse event

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 Rate of errors per 100 clinic visits 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* Review of Medications Parent Interview Identification of Strategies to Prevent Errors 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 Overall, 60% of children had a medication error found on a home visit

10. Parent use of support tools associated with significantly less errors * 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 mistakes1 • Regimens that fit with a normal routine work better2 • 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 it3 • Holdsworth, Arch Pediatr Adolesc Med. 2003 • Field T, Mazor K, Briesacher B, et. al., Journal of the American Geriatrics Society. 2007 • 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 effects1,2,3 • 60% of children with chronic conditions are given medicine by multiple difference caregivers4 • We found: Mom, Grandma, aunts, babysitter, Dad, parents roommates, others • Field TS, Mazor KM, Breisacher B, et. al.,J Am Geriatr Soc 2007 • Bedell S, Jabbour S, Goldberg R, et. al., Arch Intern Med 2000 • Weingart S, Gandhi T, Seger, et. al., Arch Int Med 2005 • Walsh K, Mazor K, Stille C, et. al., Arch Dis Child in press

16. 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 Prevention:Have parents bring in medications

17. Group Prescription and verbal instructions Prescription with syringe and demonstration Prescription, syringe with a line marked, and demonstration How they did 37% correct dose 83% correct 100% correct 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. 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

20. Prevention:Doctor-parent brief communication guide

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 communication guide and try it with them Link to Brief Communication Guide for doctors

22. Learning objectives • Residents will know what difficulties children and families experience in home medication use and will identify child and family risk factors for these difficulties • Residents will develop skills in inquiring about home medication use, identifying difficulties, and working with families to develop systems-based solutions to prevent problems • 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.