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Theses & Dissertations
Boston University Theses & Dissertations
2016
Effectiveness of a low literacy,
pictographic tool in improving
pediatric provider medication
counseling and parent dosing
accuracy
Sanchez, Dayana C.
http://hdl.handle.net/2144/17049
Boston University
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BOSTON UNIVERSITY
SCHOOL OF MEDICINE
Thesis
EFFECTIVENESS OF A LOW LITERACY, PICTOGRAPHIC TOOL IN
IMPROVING PEDIATRIC PROVIDER MEDICATION COUNSELING
AND PARENT DOSING ACCURACY
by
DAYANA C. SANCHEZ
B.A., New York University, 2011
Submitted in partial fulfillment of the
requirements for the degree of
Master of Science
2016
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© 2016 by
DAYANA C. SANCHEZ
All rights reserved
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Approved by
First Reader
Theresa A. Davies, Ph.D.
Assistant Professor of Medical Science & Education
Director, M.S. in Oral Health Sciences Program
Second Reader
H. Shonna Yin, M.D., M.S.
Assistant Professor of Pediatrics and Population Health
New York University, School of Medicine
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EFFECTIVENESS OF A LOW LITERACY, PICTOGRAPHIC TOOL IN
IMPROVING PEDIATRIC PROVIDER MEDICATION COUNSELING
AND PARENT DOSING ACCURACY
DAYANA C. SANCHEZ
ABSTRACT
Background: Parent medication errors are exceedingly common, with one child
experiencing an outpatient medication error every 8 minutes. In a previous randomized
controlled trial where the intervention was carried out under ideal conditions, we
examined the efficacy of a pictographic, health literacy-informed medication instruction
sheet-based intervention (HELPix) in reducing parent dosing errors. While our
intervention was efficacious in reducing errors, reproducing these results in a real world
setting, is necessary to examine the true effectiveness of HELPix.
Objectives: 1) To examine the impact of HELPix implementation on parent medication
dosing errors. 2) To assess the effect of HELPix implementation on provider use of
medication counseling strategies.
Design/Methods: A pre-implementation/post-implementation study design was used in 2
pediatric Emergency Departments (EDs) in New York City, one with planned
implementation of the HELPix intervention (HELPix site) and the other a control site
within the same hospital network. Subject inclusion criteria included: 1) English or
Spanish-speaking parent, 2) child <9 years old, child prescribed a short course (!14 days)
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daily liquid medicine, and 3) parent present with the child in the emergency department
and received medication counseling.
Parents were recruited over the phone; those who enrolled completed a phone interview
along with a follow-up in-person assessment (median time to follow-up=15 days). ED
providers (residents, fellows, attendings) were also recruited. The HELPix intervention
consists of: 1) provider provision of patient- and medicine-specific pictographic
instruction sheets, 2) provider use of pictures/drawings as part of counseling to reinforce
dosing information, 3) provider demonstration of the dose using an oral syringe, 3)
teachback of dose information, 4) parent showback of the dose they plan to give, and 5)
provider provision of an oral syringe. At the HELPix site, ED providers were trained in
the use of HELPix counseling strategies as well as how to use the electronic medical
record (EMR) system to generate the instruction sheets while ordering a prescription.
Outcomes assessed were: 1) provider provision of HELPix instruction sheets via web
tracking, 2) dosing errors " 20% deviation from prescribed dose, assessed from
observation at follow-up visit, 3) provider counseling practices (i.e. use of
pictures/drawings, demonstration, teachback, showback, provision of dosing tool)
obtained by parent report.
Results: A total of 1493 parents were assessed by telephone for eligibility in the pre/post-implementation phases. 561 parent-child dyads were recruited by phone (284 at
HELPix site; 277 at control site). A total of 92% were mothers, 52% were Spanish
speakers, 78% were Latino, 16% were Black, and 85% were of low socioeconomic
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status. Web tracking at the HELPix intervention site indicated that for 58% of the
enrolled families in the post-implementation period, providers generated HELPix
medication instruction sheets. Compared to the pre-implementation period at the
intervention site, parent dosing errors rates were significantly reduced during the postimplementation period (37% versus 16%; AOR=0.3, p<0.001); with an overall Relative
Risk Reduction (RRR)=57%, with greatest reductions in errors among those that received
HELPix sheets (12% error rate, RRR=68%). Providers at the HELPix implementation
site were significantly more likely to use recommended provider counseling strategies
post-implementation compared to pre-implementation (pictures/drawings: 37% versus
1%; dosing demonstration: 59% versus 33%; teachback: 24% versus 8%; showback:
33% vs. 13%, and provision of oral syringe 79% versus 25%; p<0.0001 for all
strategies). In the non-intervention site, there were no differences in parent dosing error
rates, or in provider use of counseling strategies between the pre- and postimplementation periods.
Conclusion: Implementation of the HELPix intervention resulted in increased provider
use of recommended counseling strategies as well as decreased parent medication dosing
errors in an urban public hospital setting serving low socioeconomic status families. Use
of HELPix supports high quality provider medication counseling and appears to be
feasible to incorporate as part of routine Emergency Department discharge practices.
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TABLE OF CONTENTS
TITLE……………………………………………………………………………………...i
COPYRIGHT PAGE……………………………………………………………………...ii
READER APPROVAL PAGE…………………………………………………………..iii
ABSTRACT .......................................................................................................................iv!
TABLE OF CONTENTS ..................................................................................................vii!
LIST OF TABLES .............................................................................................................ix!
LIST OF FIGURES.............................................................................................................x!
LIST OF ABBREVIATIONS ............................................................................................xi!
INTRODUCTION...............................................................................................................1!
Pediatric Liquid Medication Errors .............................................................................1!
Health Literacy and Medication Errors .......................................................................6!
Provider Medication Counseling Strategies ................................................................9!
Role of Information Technology in the Reduction of Medication Errors .................13!
Specific Aims ............................................................................................................15!
METHODS........................................................................................................................17!
RESULTS..........................................................................................................................26!
Receipt of the HELPix Medication Instruction Sheet ...................................................28!
Parent Dosing Errors .....................................................................................................29!
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DISCUSSION ...................................................................................................................32!
REFERENCES ..................................................................................................................37!
CURRICULUM VITAE ...................................................................................................44!
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LIST OF TABLES
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Table
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Title
Page
1
Summary Table of Provider Medication Counseling
Strategies
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Characteristics of the 2 Hospitals
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Use of Counseling Strategies in ED
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LIST OF FIGURES
Figure
1
Page
Bilingual (English and Spanish) HELPix Instruction
Sheets
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Questions to Assess Provider Use of Medication
Counseling Strategies, by Parent Report
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Recruitment and Eligibility Flow Chart for Pre- and PostImplementation Phases
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Parent Dosing Errors by Site and Intervention
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Title
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LIST OF ABBREVIATIONS
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AAP ..................................................................................American Academy of Pediatrics
AAPCC....................................................American Association of Poison Control Centers
AAR ................................................................................................ Absolute risk reduction
ACA...................................................................................................... Affordable Care Act
ADEs ................................................................................................... Adverse drug events
AHRQ............................................................ Agency for Healthcare Research and Quality
CDSS ................................................................................Clinical decision support system
CPOE............................................................................. Computerized provider order entry
ED....................................................................................................Emergency Department
EMR ...........................................................................................Electronic Medical Record
FDA ......................................................................................Food and Drug Administration
HELP ..................................................................Health Education and Literacy for Parents
HELPix ................Health Education and Literacy for Parents project pictogram-based tool
HHS ..........................................................U.S. Department of Health and Human Services
HL.................................................................................................................. Health literacy
HITECH ..................... Health Information Technology for Economic and Clinical Health
HS .......................................................................................................................High school
IOM ..................................................................................................... Institute of Medicine
IT ...................................................................................................Information Technology
LEP ..........................................................................................Limited English proficiency
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NIH ...........................................................................................National Institutes of Health
NNT ................................................................................................ Number needed to treat
NYU .................................................................................................. New York University
PRN .................................................................................As needed medicine (pro re nata)
RCT ......................................................................................... Randomized controlled trial
RRR ..................................................................................................Relative risk reduction
SES .................................................................................................... Socioeconomic status
S-TOFHLA .......................................................... Short Test of Functional Health Literacy
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INTRODUCTION
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Pediatric Liquid Medication Errors
The American Association of Poison Control Centers (AAPCC) defines an
unintentional therapeutic error as
“an unintentional deviation from a proper therapeutic regimen that
results in the wrong dose, incorrect route of administration,
administration to the wrong person, or administration of the wrong
substance.”1
These unintentional therapeutic errors, also known as dosing errors can include
inconsistent medication adherence and incorrect route of administration, but more than
40% of the time are due to inaccurate dosing amounts.2 Medication dosing errors are
preventable sources of adverse drug events (ADEs) in the U.S.; there were over 250,000
cases noted by the AAPCC for these errors alone in 2014.1,3 Errors can occur in the
hospital, pharmacy, or home setting; medication errors at home are most common.4 The
severity of these errors varies with the type of prescription, with errors involving
medicines with narrow therapeutic windows especially likely to lead to more harmful
health consequences, including hospitalization and even death. Over-the-counter drugs
and antibiotic medications have been implicated as the most frequent sources of
medication errors in adults. Medication underdosing may also be problematic,
contributing to incomplete treatment, ineffective therapeutic effect of regimens, and can
ultimately result in greater incurred health care-related costs.5
Medication use among children is common, with more than half of children
taking at least one medication during a given week.6 Most children’s medicines come in
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the form of liquid formulations; liquids are easier for young children to swallow and as
dosing for children is typically weight-based, doses can be easily individualized with
liquid formulations.7 Unfortunately, liquid medications are associated with higher rates of
dosing errors. From 2002-2012, the National Poison Data System from the AAPCC
attributed over 80% of medication errors in pediatric outpatient populations to liquid
formulations; for infants under a year of age, liquid formulations were responsible for
90% of medication errors.8 Pediatric populations are therefore placed at higher risk for
dosing errors compared to adults, who often take pills or tablets. In fact, young children
in the U.S. experience a medication error once every 8 minutes, and administration errors
account for the majority of preventable adverse drug events in the outpatient
population.8,9 Parents and caregivers are particularly challenged by liquid formulations;
studies estimate that 33-44% of parents incorrectly measure medication doses for their
children.10,11 Each year in the US, these errors contribute to over 10,000 calls to poison
centers and 70,000 emergency department (ED) visits.1,8,12 Of note, compared to adults,
children are more physiologically susceptible to having an adverse effect due to an
incorrect medication dose, and are more limited in their ability to communicate, making
the identification of strategies to reduce medication errors in children an important
priority.13
Pediatric liquid medication errors are attributable to many factors. Parents must
navigate a complex process to determine how to safely administer a medication to a
child. In the health care setting, once a decision is made to prescribe a child a medication
to take at home, a prescriber must determine the correct medication and calculate the
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correct dose, after which parents may receive counseling about the medication from a
number of different health care personnel (prescribing stage). Prescriptions may be given
to parents handwritten or printed, or they may be electronically transmitted to a
pharmacy. Parents may or may not receive a dosing tool if a liquid formulation is
prescribed. Parents then typically travel to the pharmacy to pick up their medication, and
may or may not receive additional verbal counseling by the pharmacist (dispensing
stage). At home, parents must read the written information on the bottle as well as any
accompanying patient information leaflets about their child’s medication to determine
how to accurately dose the medication (administration stage). At each stage of this
process (prescribing, dispensing, administration) mistakes can occur.
About one in five children given a medicine in the pediatric outpatient clinic
receives a prescription with an error.13 Reasons for errors that occur at the prescribing
stage include problems in ordering, failures in prescribing treatment, incomplete
prescriptions, and/or administrative issues.14 Mistakes in manually calculating weightbased doses happen frequently because physicians must compute doses based on accurate
weight readings, perform unit conversions from pounds to kilograms, and calculate daily
dose amounts for short-course treatment regimens.13,14 Trouble in communication handoffs between physicians and other staff and/or pharmacies also contribute to incorrect
medication orders.14 For example, one study found that in the outpatient clinic,
inappropriate name abbreviations occurred 20% of the time, and illegible physician
handwriting contributed to problems in interpreting frequency, duration, and dose.15
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The dispensing stage of the medication process involves the transaction of
providing the medication to the family at the pharmacy. Medication labels are often
designed in a way that is not patient-centered; a study conducted involving labels from
several states in the U.S. found that items emphasized with color and highlighting are
frequently pharmacy-centric (e.g. pharmacy logo) rather than patient-focused (e.g.
medication name, medication instructions).16 In addition, labels may be inconsistent with
the original prescription. Parents may get counseled on a dose in metric units at the
hospital, and receive a non-metric medication label at the pharmacy.12 The written
materials that accompany medication bottles, often referred to as patient information
leaflets, are typically at a high reading level (between 9th to 11th grade), much more than
the basic national reading level.17,18 Medicines at the pharmacy are also dispensed with
complex or inadequate dosing tools that require multiple measurements for
administration of a singular dose.17 An analysis of pharmacies found that these
inconsistencies occurred 25% of the time with the most commonly prescribed pediatric
liquid medicines.19
The administration stage involves caregiver measurement and provision of
medicine to their children at home. Most preventable ADEs occur during this stage; 40%
of caregivers make errors in dosing liquid medications due to misunderstanding of
medication instructions.20 Parent knowledge and skill are important for accurate dosing;
poor provider-parent communication is a major contributor to error.21 Parents may
experience confusion due to suboptimal medication counseling in the clinic or hospital
setting as well as in the pharmacy setting; by the time they get home, they may have little
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to no knowledge about how to correctly administer the prescribed medicine.12 Part of the
confusion may arise from difficulty understanding the units of measurement found in
medication instructions; terms like “mL,” “teaspoon,” and “tablespoon” lead to mix-ups
as these terms may be used interchangeably by providers and on medication bottle
labels.12,22-24 Parents may also lack experience with and hold misconceptions about using
dosing tools (e.g. oral syringes, dosing cups, dosing spoons, and droppers).12 Parents
most commonly use dosing cups and household teaspoons to measure medicine for their
children, despite evidence showing that dosing accuracy is typically poor with these
tools.10 Previous studies found that parents are 11 to 26 times more likely to make a
measurement error with a dosing cup in compared to an oral syringe.11 Misconceptions
contribute to errors; for example, some parents erroneously believe a full dosing cup
equals one dose.25 Parents may use nonstandardized dosing instruments, such as kitchen
spoons, to administer liquid medications out of ease of use and the belief that a spoonful
is equal to a tablespoon; studies have found that between 20-73% of parents use kitchen
spoons to administer liquid medications.26,27
The ED is an especially crucial setting to address preventable pediatric
medication errors. While lower rates of prescribing errors (between 4-10%) have been
seen in the ED compared to pediatric outpatient clinics, a larger proportion of medication
errors that arise from the ED setting are clinically significant.28,29 The fast-paced nature
of the ED is thought to be a contributing factor in prescribing errors; logistical issues,
such as staffing, time constraints, and physician training levels play a role.28,29 The setting
of the ED also contributes to parent administration errors. At ED visits, caregivers may
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be asked to incorporate and make decisions based on high levels of health knowledge in a
acute and time-sensitive manner, making adequate communication and counseling
especially important for parents. Unfortunately, current standard ED discharge practices
leave many patients/parents without adequate comprehension of discharge instructions
and treatment regimens, and some are not even aware of a gap in their understanding.30,31
Printed ED materials are also often written at a ninth-grade reading level or higher, above
the national recommendation for a sixth to eighth-grade reading level for health
materials.32 One study found that almost half of ED patients in their sample were unable
to understand their printed discharge instructions.33 Those with low health literacy and
limited English proficiency face particular difficulties in understanding how to follow
medication instructions.
Health Literacy and Medication Errors
Health literacy (HL) is defined by the National Institutes of Health (NIH) as
“the degree to which individuals have the capacity to obtain, process
and understand basic health information and services needed to make
appropriate health decisions.”34
This definition extends beyond an individual’s ability to read and understand
words. It includes prose literacy, document literacy, and quantitative literacy. Prose
literacy is the more conventional definition of literacy, and involves the skills needed to
“search, comprehend, and use information from texts…organized in sentences or
paragraphs.”18 Document literacy involves information found from non-continuous texts
in various formats, such as forms, drug and food labels, schedules, etc. Quantitative
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literacy involves performing tasks with numbers, including using numbers in printed
materials, and understanding mathematical or numerical information such as concepts
like dose amounts and frequency, as well as numbers and percentages related to risks and
benefits.18 Numeracy is particularly important for medication treatment; a national study
of adult literacy found that 62% of uninsured adults would not know what time to take a
medication, even when given the bottle instructions and time of the last meal.35 Overall,
HL affects how an individual is able to navigate the health care system, access health
resources, and communicate in the clinical setting.36 An individual with low HL can be
highly educated, but still experience difficulty in understanding, using, and accessing
health care.
Low HL has been linked to various adverse health outcomes, including increased
rates of hospitalization, worse chronic disease management, decreased use of preventive
care services, and higher morbidity and mortality. For these reasons, national policy goals
by the U.S. Department of Health and Human Services, (HHS) Healthy People 2010 and
2020, have targeted HL as an issue to be addressed.37,38 Similar initiatives have also been
issued by the NIH, the Agency for Healthcare Research and Quality (AHRQ), the Food
and Drug Administration (FDA), the Institute of Medicine (IOM), the Joint Commission,
as well as the Affordable Care Act (ACA).21,39
A 2003 national assessment found that one out of every three U.S. adults has
basic or below basic HL. Low HL is disproportionately seen in Black and Hispanic
adults; low HL is also more common among those with lower household incomes, lower
educational attainment (some high school or less), and limited English proficiency
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(LEP).18 LEP constitutes someone who speaks English “not well” or “not at all”. When
examining parents in the national sample, about 30% of parents were found to have low
HL. Sociodemographic trends were comparable; low HL was more common among
parents with less than a high school education and who had LEP.40
Having a parent with low HL can have a significant detrimental impact on a
child’s health. Children of parents with low HL are twice as likely to be uninsured, have
inadequate chronic disease management, and visit the ED more often.40-43 Children are
also more likely to experience a medication error when their parent/caregiver has low
HL. The process of administering medication correctly to children can be a highly
involved process, requiring parent understanding of instructions, the ability to use dosing
tools to measure liquid doses accurately, and being able to determine the timing and
duration of doses. Parents with low HL are three times more likely to report difficulty in
reading and understanding medication labels compared to parents with adequate HL.40
Labels may be challenging due to their non-patient-centered design and its accompanying
print materials, often written at too high of a reading level.44,45 Low HL has been
associated with poor patient knowledge of the names of medicines they are taking.46 Low
HL has also been found to be significantly associated with measurement errors across the
range of standardized dosing instruments (e.g. oral syringes, droppers, dosing
spoons).10,11,45 Of particular concern is the association of between low HL and larger
dosing errors (measured as >40% deviation), where there is a greater potential for adverse
effects.11 Understanding dosing frequency is also a challenge for parents with limited
literacy; frequency instructions like “take one tablet by mouth twice daily for seven days”
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can be difficult for patients to comprehend, and correlates with worse adherence to
medication regimens.22,23 Clearly, effective communication as part of the provision of
discharge instructions is paramount to guiding parents with low HL to safely administer
medications to their children. Parents with LEP are disproportionately at risk for low HL,
and would especially benefit from intervention strategies to enhance communication at
the time of ED discharge.47,48
Provider Medication Counseling Strategies
While a body of literature supports the use of HL-informed communication
strategies to improve parent understanding of medication instructions, to our knowledge,
this approach has yet to be systematically implemented in the ED setting.9,30,36 Best
practices include use of both verbal counseling and written materials, along with
assessment of comprehension.21,49 These HL-informed medication counseling strategies
include the use of plain language, pictures and/or drawings, provider dose demonstration,
teachback, showback, and provision of a standardized dosing tool (i.e. oral syringe)
(Table 1).
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Table 1. Summary Table of Provider Medication Counseling Strategies
Counseling Strategy
Definition
Use of plain language
Simple language used as part of both verbal and
written instructions; easy-to-read documents; overall
clear, patient-focused communication
Use of pictures/drawings
Provider dosing
demonstration
Teachback
Use of pictorial aids during medication counseling
Providers shows parent/caregiver how to measure
the correct dose amount using a standardized dosing
tool (i.e. oral syringe)
Provider verbally asks a parent/caregiver to use
his/her own words to explain the medication
instructions back to the provider
Provider asks parent/caregiver to physically
demonstrate how they will measure and administer a
Showback
medication dose to the child using the standardized
dosing tool
Provider gives parent/caregiver a standardized
Provision of a dosing tool dosing instrument (i.e. oral syringe) to take home to
use
Plain language has been emphasized as a “universal precautions” strategy for
providers to use, and is one of the few HL-related principles recommended across federal
agencies.50 Plain language is considered a basic communication strategy, and refers to
clear, simplified communication, or information that is easy to comprehend, with
avoidance of medical jargon.
Advanced counseling strategies include additional strategies such as use of plain
language written materials to supplement provider verbal counseling.51 Written materials
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may include the use of pictures and drawings, which is recommended by the Joint
Commission as a key approach to bridge the health literacy gap in provider-patient
communication.21 Numerous studies have demonstrated the usefulness of pictures and
pictograms in reducing errors, improving recall, adherence, and medication
knowledge.7,52 This is especially true for caregivers with limited HL, who may
disproportionately benefit from pictographic images.53
Provider dosing demonstrations can improve patient dose knowledge.20,26 Parents
across the HL spectrum express interest in receiving dosing demonstrations during ED
encounters.54 Whether a provider teaches patients how to read and use oral syringes, or
simply marks syringes for them, this strategy has been associated with reductions in
dosing errors when used in conjunction with provision of the dosing tool.26
Assessing caregiver comprehension is a vital step in the ED discharge process.
Teachback and showback have been found to improve the clarity of communication in
physician-patient encounters.21,55 Teachback is one of the more researched and supported
verbal counseling strategies a provider can use, and is currently recommended as part of a
Healthy People 2020 objective focused on improving health communication.38 When a
patient verbally summarizes what they learned back to their provider in their own words,
providers can gauge the clarity of their counseling and assess any knowledge or
communication gaps. Patients in the ED counseled with teachback techniques are twice
as likely to understand their prescribed medications, and nearly four times as likely to
remember their follow-up instructions when compared to standard care.56 However, some
studies have shown this strategy to be used less than 10% of the time in the adult ED, and
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9% of the time in the pediatric ED.20,57 Using showback (or checkback) where parents are
asked to show the dose amount and technique to the provider is another valuable method
for providers to assess patient ability in measuring the correct dose.53
Lastly, ED provision of a dosing instrument for caregivers to take home decrease
the likelihood that parents will use a nonstandard kitchen spoon at home and promotes
dosing accuracy.20 Oral syringes, in particular, are associated with the least amount of
dosing errors among parents across all HL levels.11 A recent policy statement by the
American Academy of Pediatrics’ (AAP) Committee on Drugs recommended provision
of standardized dosing tools to parents, and noted that these tools be the appropriate size
for the volume prescribed.58
While research supports the use of the advanced counseling strategies described
above, their use in general practice is limited. A majority of providers report that they
have not been formally taught about HL, and have not been trained in HL-informed
communication techniques.59,60 Physician attitude and awareness of guidelines are
potential barriers to clinical guideline compliance. Provider’s lack of agreement, lack of
familiarity, and low outcome expectancy are possible reasons for the limited use of
recommended counseling strategies.61 External systemic barriers also contribute to
noncompliance. In the ED, large patient loads, lack of staff and manpower, lack of
familiarity with the patient’s medical history, and time constraints can complicate the
physician-patient encounter.62 Because of the amount of physician responsibilities in the
ED, it has been recommended that the educational process should not solely involve
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physicians but include other staff, and that interventions should be designed such that
they do not interfere with ED flow.
Role of Information Technology in the Reduction of Medication Errors
In order to address medication errors, researchers and organizations have
emphasized the importance of systemic interventions. The IOM proposed the use of
computerized medication prescribing to increase patient safety in 2001, and the HITECH
(Health Information Technology for Economic and Clinical Health) Act in 2009 provided
outpatient physicians and hospitals with economic incentives to improve health
information technology (IT).4 As a result, computerized provider order entry (CPOE) has
been adopted by many hospitals across the country. The electronic-prescribing system
serves to streamline the prescribing and dispensing stages of the medication process, and
also provides clinical decision support system (CDSS) tools. CDSS tools are patientspecific (e.g. specific age, weight, medical history), and systematically raise red flags if
physicians make mistakes or omit information (e.g. the wrong medicine, diagnosis,
therapeutic dose). Dissemination of CPOE has decreased preventable prescribing errors
by as much as 48%, as it catches these errors before they are sent to the pharmacy and
eliminates the errors posed by illegible handwriting and written information.63 In
addition, more hospitals are using electronic medical record systems (EMR) that allow
them to identify and target scenarios where errors more commonly take place, and with
which medications.64 EMRs can also facilitate communication between providers during
patient transitions of care.
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However, solely relying on an EMR system or on CPOE to catch errors still
leaves room for medication prescribing errors.65 One study in four adult outpatient clinics
found no significant differences in prescribing errors between clinics that used and did
not use EMR systems, yet still found substantial error rates and preventable ADEs that
could have been avoided by physician review.66 Furthermore, CPOE and CDSS tools
may effectively catch prescribing errors, but significant amounts of medication errors still
occur during the dispensing and administration stages of the medication process. This
further supports the need for both systemic and human interventions.
Ultimately, to ensure safe parent medication administration, EMR-based tools, in
combination with the previously mentioned provider use of advanced HL-informed
counseling strategies is likely to be needed.26 Interventions that implement these
counseling strategies have shown promise in the areas of medication counseling and
chronic disease management. For example, a diabetes management intervention that
incorporated plain language, teachback, and pictorial materials showed marked
improvements in blood glucose levels over a longer period of time.67 To date, no study
has assessed how to promote the use of a systematic approach to enhance provider use of
HL-informed communication strategies as part of medication counseling in the ED
setting in conjunction with an EMR-based tool to reduce pediatric liquid medication
administration errors.
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Specific Aims
To address this gap in the literature, we developed a pictogram-based intervention
called HELPix. HELPix was developed as an extension from the New York University
(NYU) and Bellevue Hospital Center’s Health Education and Literacy for Parents
(HELP) project. HELPix (HELP project pictogram-based tool) uses plain language,
patient-and medication-specific instruction sheets to support and enhance provider
medication counseling, including improving parent knowledge of the correct use of
dosing tools. The intervention was designed to decrease parent dosing errors and increase
adherence, particularly among low literacy, LEP parents that are particularly susceptible
to these errors.
A randomized controlled trial (RCT) efficacy study of HELPix, in which the tool
was administered by trained study staff in a public hospital pediatric ED setting, found
that HELPix decreased medication dosing errors (HELPix vs. standard care: 5% vs. 48%
parents making errors) and improved adherence (HELPix vs. standard care: 9% vs. 38%
of parents non-adherent).53
A study is now needed to test the effectiveness of HELPix when implemented in a
real world setting, where ED providers are trained and given the option to use the tool as
part of routine clinical care. Our specific aims are:
1.
Examine the impact of HELPix implementation on parent medication
dosing errors.
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2.
Assess the effect of HELPix implementation on provider use of health
literacy-informed medication counseling strategies.
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METHODS
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Settings and Participants
A pre-/post-implementation study to improve parent understanding of medication
instructions was conducted to evaluate the planned implementation of the HELPix EMRlinked tool at Bellevue Hospital Center.53 Parents of children seen in two public hospital
pediatric EDs (Bellevue Hospital Center, Woodhull Medical Center) were recruited
between April 23, 2013 to December 22, 2014.
Assessment of eligible families was conducted in a similar fashion during the preand post-implementation phases, first through chart review and then by phone. Through
chart review, we screened for the following inclusion criteria: primary caregiver of a <9year-old child who was prescribed a daily dose short course (<14 days) liquid medication
in the pediatric ED. We also screened for the following exclusion criteria: caregiver was
not the legal guardian, not English or Spanish-speaking, residency outside of New York
City, child was admitted to the hospital, child with psychiatric or child protection-related
issue, and no listed phone number. Through phone screening, we assessed the additional
exclusion criteria: no eligible medication prescribed, and caregiver reached by phone was
not the caregiver counseled in the ED.
Eligible caregivers, including parents and legal guardians alike, were contacted by
phone between 4 days to two weeks after the end date of the prescribed medication
course. Every eligible parent was contacted at Bellevue Hospital, but every 4th parent at
Woodhull Medical Center was contacted due to a larger eligible patient population.
Assessments were completed by phone by trained bilingual (English and Spanish)
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research assistants, and in-person follow-ups were scheduled within 8 weeks of the end
date of the prescribed medication course. Follow-ups allowed for in-person dosing
observations as well as for completion of health literacy assessments.
Verbal and written informed consent was acquired prior to enrollment in either
English or Spanish, based on caregiver language preference. A $20 gift card was given to
subjects as an incentive for enrollment. The study was approved by the NYU School of
Medicine Institutional Review Board, and the Bellevue and Woodhull Facility Research
Review Committees.
HELPix Intervention
The HELPix intervention consists of provision of plain-language and pictogrambased medication instruction sheets in English and/or Spanish, which serve as a
framework for provider counseling, along with provider use of evidence-based HLinformed counseling strategies, specifically: use of pictures/drawings, provider dosing
demonstration, verbal teachback of dose, parent showback of the dose, and provision of
an oral syringe (1-, 2-, 5-, or 10-mL oral syringe). At the time a medication was
prescribed, providers were given the option to click a button in the EMR to automatically
generate patient- and medication-specific instruction sheets pre-populated with the
medication name, concentration, route, dose, dose frequency, and treatment duration,
along with an accompanying medication log for parents to keep track of administered
doses (Figure 1).
18
Figure 1: Bilingual (English and Spanish) HELPix Instruction Sheets (Page 1 and Page 2, scaled down)
!
19
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Sheets were developed using data from standard pharmaceutical references and
generated by a web-based application created by the NYU Langone Medical Center IT
group for this study. Over 50 of the most common liquid and pill medications were
supported by the tool, with over 300 variations; separate templates were utilized for daily
dose and as-needed medicines.
Pre-implementation Period
During the pre-implementation period, data was gathered from both sites in a
similar fashion. Parents were provided with routine standard medication counseling,
which typically included verbal medication counseling by a physician as well as by a
nurse.
Post-implementation Period
At the HELPix intervention site, once the HELPix EMR-based tool was
implemented, recruited providers were briefly trained by a research coordinator, at the
beginning of their rotation through the pediatric ED, on how to automatically generate
and manually create the HELPix instruction sheets through the EMR system. Attendings
were also trained at the beginning of the post-implementation phase. Two physician
champions were identified to help promote the use of the tool and to notify study
personnel of any provider issues or concerns. Providers were instructed to use the
HELPix sheets and counseling strategies with parents as part of their medication
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discharge routine, and to provide parents with a syringe. Our study team kept a stock of
oral syringes available in the ED.
Families at the control site were counseled using standard care practices, as was
done in the pre-implementation period.
Measures
Measures were collected through chart review, phone assessments and in-person
follow-ups. The primary outcome variable was medication error. The secondary outcome
variable was provider use of health literacy-informed counseling strategies. The primary
predictor variable was HELPix implementation status. Several patients were prescribed
multiple daily-dose medications. For these patients, only information related to the first
medication listed (longest treatment duration) was included in data analyses.
Prescriptions for step-down dose medications were analyzed using data related to the
dose most frequently given.
Receipt of HELPix Pictographic Medication Sheet
Receipt of the HELPix application was assessed via web tracking. Web tracking
identified the child’s name, prescribed medication, time and date of use, language of
sheet given, and the provider responsible for generating the sheets.
Parent Dosing Error
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Through chart reviews, we collected data on the child’s prescribed dose,
frequency, and duration. The interviewer asked parents to verbally report the dose they
gave their child over the phone, and were observed in-person measuring out the dose
given. Measurement errors of the prescribed dose (parent administration errors) were
analyzed. Parents were categorized as making a dosing error if the amount they measured
deviated by more than 20% of the prescribed dose. A 20% cut-off point was used to
define a clinically relevant dosing error, as has been done in prior studies.20,53
The in-person dosing assessment was conducted as part of the follow-up
appointment using a previously established protocol.68 Parents were first asked to bring
any materials they used at home, including the medication bottle, dosing tool, and any
instructions they received in the ED or at the pharmacy. Using a standard, unlabeled
medication bottle filled with Children’s Tylenol, caregivers were asked to dose the
medication as they would at home using the tool they brought from home, or a tool that
most closely resembled what they used from a set provided by the study team. The
options for dosing instruments, as provided by our research staff, included: a kitchen
teaspoon, kitchen tablespoon, dosing spoon, measuring spoon, dosing cup, 5-mL dropper,
acetaminophen infant dropper, ibuprofen-specific dropper, and 1-, 3-, 5-, 10-, and 12-mL
syringes.
The parent measured dose was compared to the dose prescribed (obtained by chart
review) to determine any dosing error. Parents who deviated by more than 20% were
categorized as making an error. Interrater reliability, measured by having 2 raters (DS,
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DU) assess errors in parent measurement of the prescribed dose using the 20% criterion
for a subsample of 150 parents, was high (kappa>0.9).
Provider Use of HL-informed Counseling Strategies
Parent interview was employed to determine provider use of recommended health
literacy-informed counseling strategies: use of pictures/drawings, dosing demonstration,
teachback, showback, and provision of an oral syringe. Questions were adapted from
existing validated measures (Figure 2).69
Counseling strategy #1: Use of pictures and/or drawings
Did your doctor or nurse use pictures or drawings to help you understand
how to give your child’s medicine correctly?
Counseling strategy #2: Dosing demonstration
When this person showed you how to dose, did they demonstrate the dose
using a dosing instrument?
Counseling strategy #3: Teachback
Did your doctor/nurse ask you to describe to him/her how you were going to
follow the medication instructions?
Counseling strategy #4: Showback
Did you use a dosing instrument to show the nurse/doctor the dose you
planned to give your child?
Counseling strategy #5: Provision of dosing tool
Do you remember receiving something to help dose the medication in the
ED?
What did you receive? (options: dosing spoon, measuring spoon, dosing
cup, dropper, syringe, other)
Figure 2: Questions to Assess Provider Use of Medication Counseling Strategies, by
Parent Report
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Sociodemographic Data and Health Literacy
Sociodemographic data was obtained by both chart review and phone interview.
Child and caregiver age, gender, relationship, preferred language, ethnicity, country of
birth, level of education, and socioeconomic status were collected.
Relationship to the child was categorized as mother or other. Language was coded
based on the language preferred by the caregiver (language used for the telephone
interview (English or Spanish)). Because Latinos represented the majority ethnicity in our
sample, we categorized ethnicity as Latino or non-Latino. Country of origin was
categorized as U.S.-born or foreign-born. Education level was based on whether the
caregiver graduated from high school (HS). Socioeconomic status was assessed using the
Hollingshead Four Factor Index of Social Status, with a score of 1 representing the
highest resource level and a 5 representing the lowest resource level. For analyses, status
was dichotomized as Hollingshead Index of 4 or 5 versus all others.70
Caregiver health literacy level was assessed using the Short Test of Functional
Literacy (S-TOFHLA), administered in English or Spanish at the time of the in-person
follow-up appointment. The S-TOFHLA is a widely used health literacy assessment tool,
that consists of a 36-item reading comprehension test that must be completed in 7
minutes.71 Subjects are categorized as having inadequate, marginal, or adequate health
literacy.72
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Statistical Analyses
Data was analyzed using SPSS 20.0 (SPSS Inc., Chicago, IL). For all analyses, a
2 tailed p-value <0.05 was considered to be statistically significant. Characteristics of
families at the two sites, pre- and post-implementation, were compared using t-tests and
chi-square tests, as appropriate. We assessed unadjusted associations between outcomes
of interest (dosing error, provider use of health literacy-informed counseling strategies)
and HELPix implementation status and site using bivariate analyses with chi-square or
Fisher’s exact tests, as appropriate. Multiple logistic regression analyses were conducted
with a priori adjustment for potential confounders, including child and parent age,
language, race/ethnicity, US country of birth, SES, education, and health literacy. Site by
time interaction terms were used to see if there were differences in use of strategies and
dosing error rates between sites, pre- and post-implementation. To specifically examine
the impact of the HELPix instruction sheets on dosing errors, we performed subgroup
analyses for the HELPix site to calculate absolute risk reduction (ARR), relative risk
reduction (RRR), and number needed to treat (NNT).
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!
RESULTS
Study enrollment for the pre-implementation phase took place from June 23, 2010
until September 26, 2011, and enrollment for the post-implementation phase took place
from April 23, 2013 to December 22, 2014, at each of the 2 ED sites. During this time,
there were 14,463 visits of parents and children less than 9 years of age that presented to
the ED and were prescribed short-course medications, of which 3,633 met exclusion
criteria by chart review (Figure 3).
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Figure 3: Recruitment and Eligibility Flow Chart for Pre- and Post-Implementation
Phases
The most common reason for exclusion by chart review was subject had been
previously contacted or had been previously excluded (n=2953; 81%). A total of 9347
were not reached (skipped at control site (n=5796), no answers to phone calls (n=2026),
or other issues with their telephone numbers). Of the 1,493 parent-child dyads assessed
by phone call, 1,194 were eligible (712 pre-implementation, 781 post-implementation).
The most common reasons for exclusion by phone call were: caregiver language other
than English/Spanish (n=90), and child was given an ineligible medication (n=92). Eight
hunded of those eligible were enrolled, with 71% showing up for a follow-up assessment
(71% follow-up rate at HELPix site, 71% at control site). Therefore, our final sample was
561 parents, with a median time of 15 days from enrollment to follow-up.
Study subjects were primarily mothers (92% at both sites) from low
socioeconomic backgrounds (85%), with slightly more than half having a HS education
or more (55%) (Table 2). Of short-course medications prescribed, 78% were antiinfectives (primarily antibiotics) (20% steroids, 2% other). Most common diagnoses from
the child’s ED visit were otitis media (37%), reactive airway disease (17%), and skin
infection (14%).
Significant differences were found between the 2 hospital sites with respect to
relationship of parent to the child, Spanish language, foreign-born caregivers, and Latino
ethnicity (Table 2). By pre- and post-implementation. there were some differences in
study population characteristics, with more Spanish language and Latino participants
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post-implementation (46% vs. 57%; p=0.01; 74% vs. 81%; p=0.05); parents were also
slightly older in the post-implementation period (32.2 vs. 32.9 years; p=0.01). Overall,
about a third of our total study sample had inadequate/marginal HL (35%); there was no
difference in HL level between the two hospitals or pre- vs. post-implementation.
Table 2. Characteristics of the 2 Hospitals, (n=561)
Child age, mean (SD), years
Parent age, mean (SD), years
Relationship to child, mother
U.S.-born
Parent language, Spanish
Race/ethnicity, Latino
SES, Hollingshead 4/5
Parent education, <HS
graduate
Health literacy,
inadequate/marginal
HELPix
Hospital
n=285
3.8 (2.4)
31.9 (7.1)
95%
27%
60%
85%
83%
43%
Control
Hospital
n=276
3.7 (2.5)
33.2 (9.1)
88%
48%
44%
70%
87%
48%
p-value
32%
37%
0.3
0.4
0.1
0.01
<0.001
<0.001
<0.001
0.3
0.3
Receipt of the HELPix Medication Instruction Sheet
Of the 150 parents enrolled at the post-implementation HELPix hospital, web
tracking showed 58% received the HELPix pictographic sheet. There was no statistically
significant difference in the characteristics of parents who did and did not receive the
HELPix medication instruction sheets from their provider.
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Parent Dosing Errors
Overall, in the pre-implementation phase, 41% of parents made a dosing error,
with comparable rates across both sites (37% HELPix site vs. 45% control site) (Figure
4). In the post-implementation phase, 26% dosing errors were made (16% at the HELPix
hospital, 37% at the control site). The site by time interaction was significant, with
p=0.01. At the HELPix implementation site, 21% fewer parents made dosing errors
(Absolute Risk Reduction=21%) post-implementation compared to pre-implementation
(NNT=5).
In comparing post-implementation error rates, 12% of parents who received
HELPix instruction sheets made dosing errors compared to 22% of parents who did not.
Parents who received the HELPix medication instruction sheets had the greatest
reduction in likelihood of making dosing errors, with an ARR=25%, and a RRR=68%;
those who did not receive medication instruction sheets at the implementation site had an
ARR=15% and a RRR=42%.
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60%
AOR=0.8 (NS)
AOR=0.3***
% Parents
45%
40%
37%
37%
Site by time
interaction pvalue = 0.01
Preimplementation
16%
20%
Postimplementation
0%
HELPix Hospital
Control Hospital
*** p<0.001; NS = Not significant
Figure 4. Parent Dosing Errors by Site and Intervention
Provider Use of HL-Informed Counseling Strategies
At the HELPix implementation site, there was a significant increase in use of HLinformed counseling strategies in the post-implementation period. At the control site no
statistically significant differences were seen in the rate of provider use of HL-informed
counseling strategies pre- vs. post-implementation (Table 3). Site by time interaction was
significant across each type of HL-informed counseling strategy.
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Table 3. Use of Counseling Strategies in ED
HELPix Hospital
Control Hospital
Site by time
interaction
p-value
31!
Pre
n=142
n (%)
Post
n=142
n (%)
AOR
p-value
Pre
n=142
n (%)
Post
n=133
n (%)
AOR
p-value
Use of pictures/
drawings
2 (1%)
52 (37%)
12.9
<0.01
1 (1%)
0 (0%)
--a
NS
<0.001
Dose
demonstration
47 (33%)
82 (59%)
3.6
<0.001
28 (20%)
18 (14%)
0.7
NS
<0.001
11 (8%)
34 (24%)
3.6
<0.001
15 (11%)
18 (14%)
2.0
NS
<0.001
18 (13%)
46 (33%)
3.5
<0.001
14 (10%)
14 (11%)
1.2
NS
0.005
35 (25%)
108 (79%)
16.3
<0.001
19 (13%)
19 (15%)
1.2
NS
<0.001
Teachback
Showback
Provision of
dosing tool
NS= Not significant
a
Not able to be calculated as value of 0 post-implementation at control site
!
DISCUSSION
To date, there has been limited study of effective and feasible systems-based
interventions in the ED to promote use of health literacy-informed counseling strategies
to reduce parent medication administration errors. We assessed the implementation of an
EMR-linked plain language, pictographic medication instruction sheet-based counseling
intervention in an urban, public hospital ED setting. We found that HELPix
implementation was significantly associated with higher rates of provider use of
recommended counseling strategies. Moreover, children of parents who received the
“core” part of the intervention, the HELPix medication instruction sheets, had the greatest
decreased risk of dosing errors, with a relative risk reduction of nearly 70%.
Our study findings replicate results from our prior RCT efficacy study of the
HELPix intervention, which was conducted under controlled research conditions,
demonstrating that incorporation of HELPix into “real world” routine provider
medication counseling is feasible, effective, and achievable.53 While provider use of the
specific parts of the HELPix intervention was variable, overall, regardless of the extent to
which the full suite of HELPix components was used, implementation of HELPix at the
hospital site was associated with a nearly 60% reduction in relative risk, and an
approximately 20% absolute risk reduction. This indicates that for every 5 people seen at
a HELPix implementation site, 1 person would have been prevented from making a
dosing error.
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Of note, those providers who used the EMR to generate the low literacy
pictographic HELPix medication instruction sheets had the greatest reductions in error.
The instruction sheets serve as the “core” of the HELPix intervention, providing a
framework for verbal counseling. Providers are asked to use the instruction sheets while
counseling parents, allowing HELPix sheets to remind them to systematically address key
issues while physically directing parents to its features. The image shown within the
dosing diagram on the second page of the instruction sheet (Figure 1) may have served to
“trigger” providers to counsel about the dose, demonstrate the dose, perform
showback/teachback, and reinforce the need to provide the appropriate dosing tool (i.e.
oral syringe of the appropriate size for dose). EMR generation of the medication
instruction sheets may also simply be a marker for providers who recognize the
importance of clear provider-parent communication, or were stronger “adopters” of the
idea of using health literacy-informed counseling strategies as part of the HELPix
intervention.
Even if providers did not send parents home with a HELPix sheet, parents still
made fewer dosing errors at the HELPix implementation site. This suggests there was a
likely residual effect of provider HELPix training in the pediatric ED. Even when
providers may have been rushed and did not have time to generate a HELPix sheet, they
may have recognized the importance of using health literacy-informed communication
strategies. Strategies such as using pictures and drawings and providing dosing tools are
easy to incorporate into routine counseling, and were likely being used in many situations
without the inclusion of the “core” instruction sheets, contributing to the reduction in
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parent dosing errors in this group. Also, it is possible that providers may have made a
determination for which parents needed the instruction sheets the most, reserving the use
of the sheets for those families most at-risk for error, but using the other recommended
HELPix counseling strategies for routine counseling of lower risk families.
While we did find an overall reduction in dosing errors during the postimplementation phase of our study, there was still a large amount of parents making
dosing errors. Even at the HELPix implementation site, approximately 1 out of every 5
families still made a dosing error. These findings indicate that additional interventions
may be needed, particularly for those families with low HL and LEP, who are at
particular risk for error.
The implementation of HELPix in the pediatric ED notably improved the use of
counseling strategies among providers. Provision of dosing syringes was the most widely
adopted strategy, with nearly 80% of providers supplying parents with oral syringes, an
increase of over 15 times the odds compared to the pre-implementation period.
Demonstration of how to properly administer doses was performed nearly 60% of the
time in the post-implementation period, an increase of over 3 times the odds compared to
the pre-implementation period. Use of pictures and drawings increased dramatically,
from 1% in the pre-implementation period to 37% in the post-implementation period. In
comparison, utilization of each of these techniques was rarely reported among parents at
the control site (0%-15%). Our findings highlight the persistence of low utilization rates
of recommended health literacy-informed counseling approaches in standard care
procedures, despite recommendations to use these counseling techniques from reputable
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stakeholders like the American Medical Association and the Joint Commission.21,73 Our
study findings are promising, suggesting that getting providers to adopt recommended
health communication strategies as part of medication counseling is indeed feasible with
our low intensity systems-based EMR-linked intervention.
Our study has several limitations. First, this was a pre-/post-implementation study
in which our intervention was implemented at just one ED site, which limits our ability to
draw firm conclusions about our findings. Secondly, while both sites were public hospital
pediatric EDs within the same hospital system, there were differences between sites and
between times (pre- and post-implementation) with respect to the characteristics of the
families enrolled. While we adjusted for these differences in study analyses, our study
design could have been strengthened through matched enrollment at each site, pre- and
post-implementation. Third, we relied on parent self-report for provider use of counseling
strategies, which may not accurately reflect what occurred in the physician-parent
encounter. Unfortunately, we did not have sufficient funding to record actual counseling
sessions, although that may have also led to a Hawthorne effect. Fourth, observed inperson dosing assessments may not have captured how caregivers actually administered
the medicine at home. While we asked parents to bring in the dosing tool they used with
their children, many parents did not bring that tool to the follow-up. Those parents were
asked to pick the dosing tool that most resembled what they used at home from a kit
provided our research staff, which may not have fully matched what was actually used. In
particular, the kitchen spoons parents used at home may have been different in size from
the spoons included in study kit. Additionally, since the dosing assessment also occurred
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within 8 weeks of the child’s treatment end date, it is possible that dosing errors may be
subject to recall bias. Finally, our study sample primarily consisted of low SES, Latina
mothers in NYC, limiting generalizability of our findings to other populations.
Nevertheless, this study holds promising data to support the effectiveness and
feasibility of implementing a health literacy-informed EMR-linked tool to enhance
pediatric provider counseling in the ED setting and reduce parent medication dosing
errors. Further study is needed to examine the impact of a large-scale dissemination of
HELPix across multiple sites, and explore whether there is a differential impact of
HELPix by health literacy level and English proficiency. Without placing additional
requirements on overburdened ED providers, an intervention like HELPix is promising
for the knowledge and empowerment of many vulnerable parents, and the health of many
future children.
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CURRICULUM VITAE
DAYANA C. SANCHEZ
Address: 73 Empire Street #3, Allston, MA 02134 ! Phone: (917) 880-5905
E-mail: [email protected] ! Year of Birth: 1989
EDUCATION
Boston University School of Public Health
Master of Public Health, Maternal and Child Health
09/15-05/16
Boston University School of Medicine, Graduate Medical Sciences
Master of Science, Medical Sciences
09/14-05/16
New York University
Bachelor of Arts, French major / Public Health Policy minor
09/07-05/11
WORK EXPERIENCE
Health Care For All
10/15-05/16
Public Health Fellow, Boston, MA
• Drafted, revised, and finalized a white paper on the organization’s policy
recommendations for state health agencies and hospitals to follow, in accordance with
cost and quality transparency mandated under Massachusetts state law
• Spearheaded the Best Practices and Annual Report Committees in the Leadership
Network of Patient and Family Advisory Councils (PFAC) by organizing meetings,
members, and best practices around integrating the patient and family voice at the
organizational level through all 70+ PFACs across the state
• Organized the annual PFAC Conference by coordinating topics, speakers, content, poster
presentations, roundtable discussions, trainings, invites, reservations, and materials for
informing PFACs of best practices and future directions
• Fulfilled practicum requirements as part of MPH degree, writing culminating experience
thesis on gaps between policy and practice of PFACs in Massachusetts, and its
intersection with maternal and child health
Children of Bellevue at Bellevue Hospital
05/14-09/14
Translator (Part-time), New York, NY
• Translated nutritional educational materials into Spanish for parent use in the pediatric
outpatient clinic, as part of an HHC grant to encourage parent participation and dialogue
with pediatricians
• Designed dietary handouts for easy readability for low-literacy families and children
• Edited content material to simplify language and highlight key nutritional goals
NYU School of Medicine / Bellevue Hospital
06/11-08/14
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Supervising Research Coordinator (Full-time), New York, NY
• Managed three concurrent studies, including a Robert Wood Johnson Foundation-funded
pediatric medication safety interventional study (HELPix) at two public hospitals,
Bellevue and Woodhull Hospital, an NIH/NICHD R01 funded pediatric medication
labeling study, and a CTSI childhood asthma study
• Co-authored and collected data for manuscript drafting of two academic research papers
published in Pediatrics, the official journal of the American Academy of Pediatrics,
under the Principal Investigator Dr. Shonna Yin
• Coordinated the efforts between NYU Langone Medical Center and Bellevue Hospital to
implement a health-literacy, pictographic intervention for HELPix within the electronic
medical record system
• Maintained a constant recruitment rate for studies and successfully enrolled more than
800 parents and 200 providers across Bellevue and Woodhull public hospital facilities
• Designed dietary pamphlets for dissemination across NYC Health and Hospitals
Corporation facilities, as well as pictographic asthma action plan sheets and pediatric
medication labels for interventional use in two randomized control trials
• Contributed in writing successful grant submissions and conducting literature review and
reference checking for NIH and CTSI applications
• Delegated daily volunteer research assistants to carry out study and enrollment
procedures
• Supervised and trained other research coordinators under the supervision of Dr. Shonna
Yin
Skirball Center for the Performing Arts
01/09-05/11
Usher, New York, NY
• Handled communication with patrons and coordinators in order to efficiently run events
• Coordinated groups of student volunteers to carry out specific tasks during student
organized functions
• Ensured patron satisfaction by leading them to their assigned seating, handling tickets
and queries
VOLUNTEER EXPERIENCE
Greenlight Project at Bellevue Hospital
09/10-05/11
Volunteer Research Assistant, New York, NY
• Enrolled families into NIH/NICHD-funded childhood obesity prevention study and
performed parent interviews to administer assessments
• Maintained data by scoring and organizing interview measures for data entry
• Enabled patient communication with nurses, doctors and other hospital workers through
medical translation
• Shadowed pediatric residents and attendings during their clinical encounters, including
routine well-child and asthma clinic checkups
PUBLICATIONS AND PRESENTATIONS
Yin HS, Gupta RS, Tomopoulos S, Mendelsohn AL, Egan M, Van Schaick L, Wolf MS, Sanchez
DC, Warren C, Encalada K, Dreyer BP. Using a Low Literacy Asthma Action Plan to Improve
Provider Asthma Counseling: A Randomized Study. Pediatrics. January 2016;137(1):1-11.
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Yin HS, Gupta RS, Dreyer BP, Ugboaja DC, Sanchez DC, Paul IM, Moreira HA, Rodriguez L,
Mendelsohn AL. Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics.
July 14, 2014;134:e354-e361.
Ng C, Shah A, Mendelsohn AL, Dreyer BP, Mojica M, Sanchez DC, Yin HS. Use of Enhanced
Communication Strategies for Medication Counseling by Providers Who Care for Children in the
Emergency Department. Poster session presented at Pediatric Academic Societies Annual
Meeting, 2013 May; Washington, DC.
Yin HS, Gupta RS, Tomopoulos S, Wolf MS, Mendelsohn AL, Antler L, Sanchez DC, Lau CH,
Dreyer BP. Readability, Suitability, and Characteristics of Asthma Action Plans: Examination of
Factors That May Impair Understanding. Pediatrics. January 1, 2013;131(1):e116-e126.
Sanchez DC, Bernabe K, Reyes E. Internet Predators. Poster session presented at Annual STEP
Statewide Student Conference, 2007 March; Albany, NY.
SKILLS
Language Skills: Fluent in Spanish, Highly proficient in French.
Computer Skills: Proficient in Microsoft Word, Excel, Power Point, Outlook, HTML, SPSS,
Adobe Photoshop, Adobe InDesign and Adobe Illustrator.
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