Published: Apr 29, 2013 | Updated: Apr 29, 2013
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Action Points

• Missed doses, wrong doses, and other medication errors are common among children with cancer who receive part of their treatment at home, with substantial potential for harm.
• Point out that errors had potential to harm 36 per 100 patients and actually did cause injury in four per 100

Missed doses, wrong doses, and other medication errors are rife among children with cancer who receive part of their treatment at home, with substantial potential for harm, a study showed.

Fully 47% of children were exposed to at least one medication error based on medical records, bottle checks, and direct observation by visiting nurses, Kathleen Walsh, MD, MSc, of the University of Massachusetts Medical Center in Worcester, and colleagues found.

The rate of any kind of medication error was 70 per 100 patients, the group reported in the May issue of Pediatrics.

Errors had potential to harm 36 per 100 patients and actually did cause injury in four per 100.

“The identification of even these few injuries in such a relatively small sample of children is cause for serious concern,” Christopher Landrigan, MD, MPH, of Boston Children’s Hospital and Brigham and Women’s Hospital, commented in an accompanying editorial.

The study found two life-threatening errors and 13 serious errors in administration of medication at home among the 92 patients of three pediatric oncology clinics getting chemotherapy for cancer (predominantly leukemia).

The rates were higher than expected from administration outside the home in prior studies, which showed medication errors in 2% to 19% of pediatric oncology clinic visits and an up to 4% rate of preventable medication-related injuries among hospitalized children overall.

Parents who care for ill kids need better support to match the kind of advances against medication errors achieved in hospitals, Landrigan suggested.

“Developing better communication strategies with parents will be crucial,” he wrote. “In addition, medication packaging innovations may be needed to reduce the risk of using outdated or mislabeled medications.”

The prospective analysis included medical record and prescription dose checks, as well as home visits, by a trained nurse who examined the 963 bottles of medication taken by these children, and watched parents or guardians administer one set of doses.

Altogether there were 72 medication errors as independently determined by two pediatricians or oncologists trained in error analysis, with 47% of the children exposed to at least one error.

The four cases of errors with injury were:

• One case of failure to taper a psychiatric medication as instructed, resulting in severe agitation
• Two cases of underdosed or unfilled prescriptions for antacids, both resulting in prolonged untreated chest and abdominal pain
• One case of repeated significant underdoses of acetaminophen, which didn’t relieve pain

The errors with potential to harm included two that could have been life-threatening: A methotrexate bottle was labeled to give eight tablets daily instead of weekly; and a parent was observed giving half the prescribed dose of antibiotic for fungal pneumonia prophylaxis.

Other errors included missed doses either reported by parents or based on how much was left in the bottle.

Chemotherapy was less often involved than other medications, although the typical failure of caregivers to wear gloves while administering chemotherapy doses to avoid toxicity wasn’t counted as an error.

Better communication about medication use between families and physicians might have prevented 36% of errors, the adjudicators suggested.

“Frequent changes in dose, which caused the bottle label to be outdated, were often a root cause of parent errors,” Walsh and colleagues noted.

These results may generalize beyond pediatric oncology, Landrigan proposed, noting that “many of the home medication errors identified in this study are undoubtedly experienced not only by children with cancer, but by children with other acute and chronic illnesses treated in part at home.”

The researchers cautioned that the nurse’s presence in the home may have changed behavior in such a way that would reduce errors observed, although 97% of the parents said their child took medications as usual during the home visit.

Other limitations were the small sample size and the highly-educated population of parents in the study.