Medication mix-up’s are a well-known source of errors and harm in the hospital. So we shouldn’t be surprised that similar errors occur in other settings, including the home. Medication Errors in the Home: A Multisite Study of Children With Cancer in the journal Pediatrics documents the high rate of errors in at-home administration of medications for pediatric cancer.
Error types include administering at the wrong dose or frequency, incorrect label, missed doses, using expired medication, and using the wrong administration technique. Many of the errors have the potential for harm, some caused actual harm.
From the article:
“In our study, parent administration errors were often caused by miscommunication between parents and clinicians or between in-home caregivers regarding changes in oral chemotherapy dose. Frequent changes in dose, which caused the bottle label to be outdated, were often a root cause of parent errors.”
I’ve seen similar things happen outside of oncology. Sometimes a patient is taking 10 or more medications and supplements, so it’s very hard for a parent to remember what to do even when they are well educated, organized, and have the best of intentions.
I’d like to see someone come up with a comprehensive solution to managing multiple, frequently changing pediatric medications in the home setting. I don’t have a specific solution in mind, but would be very appreciative if one came on the market.