Use of a Low Literacy Pictogram-based Intervention to Reduce Medication Errors in Low SES, Low Education Families: An RCT

Background: Liquid medication administration errors are common, and place children at risk for adverse events. Caregivers with low socioeconomic status(SES), low education and low health literacy are at increased risk for errors. Pictogram-based medication instruction and reminder sheets are a promising approach for reducing errors, but have not been well studied.

Objective: To determine whether low SES families receiving a pictogram-based intervention had improved medication knowledge, dosing accuracy, and adherence.

Design/Methods: Enrollment took place in an urban public hospital pediatric emergency service(PES). Inclusion criteria: child 30 days-8 yrs, non-urgent visit, caregiver responsible for giving medications, English/Spanish spoken, liquid medication prescribed. Caregivers were randomized to intervention or control. The intervention consisted of provision and demonstration of: 1)medication-specific pictogram-based instruction and reminder/tracking sheets; 2)oral dosing syringe. Medication knowledge (dose within 20%) and adherence (within 1 day) were assessed by interview, and dosing accuracy (within 20%) was assessed by direct observation at follow-up.

Results: 229 of 245 enrolled caregivers (93.5%) were assessed (124 intervention; 121 control), including 158 prescribed as needed(prn) and 99 prescribed daily dose medications. Intervention and control caregivers were similar for ethnicity, education, SES, and health literacy. Intervention caregivers had improved knowledge of dose (prn: 93.7% vs. 65.8%, p<0.0001; daily: 100% vs. 73.6%, p<0.0001), improved dosing accuracy (prn: 85.9% vs. 61.3%, p=0.002; daily: 94.6% vs. 50.0%, p<0.0001), and improved adherence (daily: 95.3% vs. 63.3%, p<0.0001).

Conclusions: Provision of a pictogram-based intervention resulted in improved medication knowledge, dosing accuracy, and adherence in multiethnic, low SES caregivers presenting to an urban PES.