medication errors with liquid meds in kids

Medication adherence issues are one of the most pervasive primary care conundra (?plural for conundrum). i must admit that i always cringe a bit whenever i write for liquid meds for kids, hoping that the pharmacist can appropriately explain how to take the meds and give the appropriate measuring device. (there are other types of educational issues gone awry, evidenced by parents instilling the oral liquid antibiotics directly into the ear, or people taking suppositories by mouth....). so, in this light, there was a study done in new york assessing medication errors and the potential utility of "advanced counseling" in decreasing these errors (see medical errors liq meds kids acadpeds2014 in dropbox, or DOI: 10.1016/j.acap.2014.01.003).

background: several studies have found that 40% of caregivers make errors in giving kids liquid meds. more if low levels of health literacy, or limited english proficiency. the language used in the instructions can also be confusion (writing "5ml" instead of "1 teaspoon" may be difficult for some parents; or using kitchen teaspoons instead of measuring spoons leads to dosing errors). use of "advanced counseling skills" can help, eg asking the parent to describe how they will give the med, provider demonstration esp coupled with patient demonstration, use of pictures/drawings do help... but are underutilized. 

results:

    --287 patients <9 yo from 2 urban new york public hospital ERs prescribed liquid meds. parents were asked about the quality of counseling they received and/or a dosing instrument. primary endpoint was observed dosing error, defined as >20% deviation from what was prescribed. variables controlled for include: parent age, language, country, ethnicity, socioeconomic status, education, health literacy as assessed by Short Test of Functional Health Literacy in Adults, child age and their chronic disease status. cross-sectional analysis.

    --41.1% of parents made dosing errors (81.4% underdosed, and 18.6% overdosed the med). advanced counseling was provided to 33.1%, measuring instruments provided to 19.2%.

    --97.6% of parents received some counseling in ER or pharmacy. 15% received both advanced counseling and medication instrument; 4.2% instrument only, 18.1% advanced counseling only, 62.7% neither

    --advanced counseling associated with decreased errors (30.5% vs 46.4%); instrument provision also associated with decreased errors (21.8% vs 45.7%)

    --combo of advanced counseling and instrument provision decreased odds of error, as compared to neither (20.9% vs 47.8%), with adjusted odds ratio of 0.3.

    --subgroup analysis did find that the combo strategy was significant only for those who spoke english, and those with adequate health literacy (there were essentially the same odds ratios of benefit for each of these interventions individually but were not statistically significant, perhaps because of small sample sizes)

evidence shows that advanced counseling strategies work and have the support of the AMA and other professional organizations. However, most patients/parents in this study (and, i would imagine, in most practices) do not receive such counseling regularly. Pharmacists, at least in Massachusetts, are supposed to instruct parents in detail and provide measuring instruments, though unclear what the actual details or quality of that input really is.  the current study is limited, based on patients self-report and with likely biases, but it does highlight a very important problem inherent in outpatient medications -- medication non-adherence is responsible for a huge amount of morbidity/mortality (eg, many hypertension studies find about 50% non-adherence rates) and the complexity of the medication regimens leads to more errors and non-adherence. and kids prescribed liquid meds have even more complex regimes than simply taking pills.