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
1. Residents will know what difficulties children and
families experience in home medication use and will
identify child and family risk factors for these difficulties
2. Residents will develop skills in inquiring about home
medication use, identifying difficulties, and working
with families to develop systems-based solutions to
prevent problems
3. 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
Error Error Adverse
without with event
adverse adverse without
event event error

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
sites
16 14.5
Rate of errors per 100 clinic visits
14
12
10
Pediatrics
8
5.8 Adults
6 4.3
4
2 0.7
0
Clinic Home
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* Identification of Strategies to
Review of Medications Prevent Errors
Parent Interview
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
Sickle Cell Epilepsy Cancer
(N=25) (N=28) (N=27)
Number of medications 119 154 290
Number errors 41 28 52
Rate error per 100 medications 34.4 18.1 17.9
(Confidence Interval) (25.9-42.9) (11-25.2) (12.4-23.7)
With injury 6.7 0.7 1.4
No injury but potentially dangerous 17.6 8.4 11.0
Trivial 10.1 9.1 5.5
Overall, 60% of children had a medication error found on a home visit

10. Parent use of support tools associated
with significantly less errors
No supports Supports
At least one 19 14
error at
home
No error 1 18
* 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 mistakes 1
• Regimens that fit with a normal routine work
better 2
– 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 it 3
1. Holdsworth, Arch Pediatr Adolesc Med. 2003
2. Field T, Mazor K, Briesacher B, et. al., Journal of the American Geriatrics Society. 2007
3. 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 effects 1,2,3
• 60% of children with chronic conditions
are given medicine by multiple difference
caregivers 4
– We found: Mom, Grandma, aunts, babysitter,
Dad, parents roommates, others
1. Field TS, Mazor KM, Breisacher B, et. al., J Am Geriatr Soc 2007
2. Bedell S, Jabbour S, Goldberg R, et. al., Arch Intern Med 2000
3. Weingart S, Gandhi T, Seger, et. al., Arch Int Med 2005
4. Walsh K, Mazor K, Stille C, et. al., Arch Dis Child in press

16. Prevention:
Have parents bring in medications
• 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

17. 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.
Group How they did
 Prescription and verbal 2. 37% correct dose
instructions
 Prescription with syringe 4. 83% correct
and demonstration
 Prescription, syringe with 5. 100% correct
a line marked, and
demonstration
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
Problem Recommendation
Acetaminophen or ibuprofen under Review dose at every visit
dosing
Failure to change doses or fill Ask parent to bring in all medications;
prescriptions ask about dose, timing, preparation
Problems giving medications at Ask about problems giving medication:
home general problems/refusals? vomiting?
missed doses?

20. Prevention:
Doctor-parent brief communication guide
Problem Recommendation
Miscommunication between in home •“Who gives medicines at home?”
caregivers (parents, parent and •multiple people?
babysitter, others) •Do parents have a:
•System for communicating about changes
•System for tracking whether a medication
has been given?
General Encourage to contact the clinic with any
problems with medications
Provide instructions if problems/questions
occur outside of office hours
No support tools •“Do you use anything at home to help you
give medicines?” pill box? alarms?
•If no, suggest tools
•Offer help getting started with tool

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

22. Learning objectives
1. Residents will know what difficulties children and
families experience in home medication use and will
identify child and family risk factors for these difficulties
2. Residents will develop skills in inquiring about home
medication use, identifying difficulties, and working
with families to develop systems-based solutions to
prevent problems
3. 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.