Abstracts

Rationale: Caregivers misreading and misinterpreting instructions of complex medication plans and instructions are common causes of medication errors, often due to confusion of units (e.g. mg and ml). In our institution's Epilepsy department, outpatient medication errors are one of the largest sources of adverse events identified through our Safety Events Reporting System (SERS). Many of the events have a common factor of medications with complicated formulation or administration instructions. The aim was to improve the safety of caregiver medication administration by increasing caregiver confidence in preparing and administering medications Methods: We piloted a medication education teaching session for patients at high risk for medication errors. Patients referred were identified as high risk if they met any of the following criteria: non-English speaking caregivers, new prescription, change in dose, liquid medications, Clobazam prescription, new rescue plans, or history of non-adherence. Patient and caregiver met with clinic nurse for an education session that included demonstration and successful teach back of medication preparation and administration, distribution of a toolkit, and a customized folder with relevant education sheets. Caregivers then completed a post-session survey to assess a change in confidence with medication preparation and administration, quality of the education, and any additional feedback.  Results: Between June 2018 and December 2019, 30 sessions were completed for 29 patients. Median patient age was 14 years (IQR: 14-17), and 55% of patients were male. Most sessions (73%) had a duration between 15-30 minutes, while 10% were 30-60 minutes and 17% were less than 15 minutes. Of the 26 caregivers that completed a follow-up survey, 96% (n=26) reported an increase in their confidence to correctly prepare and administer their child's medication(s) and 85% (n=26) reported they learned something new regarding an established or newly prescribed medication. All caregivers reported they agree or strongly agree that space was comfortable and teaching was clear and easy to follow. 0% (n=30) of all education session completed were followed by an emergency department visit within 30 days or a medication related SERS filed within 30 days of the session. Conclusions: A standardized education session that provides demonstration methods and tools targeted to caregivers and patients at high risk for medication errors can improve caregiver confidence with medications for children with epilepsy. Ultimately, adverse events related to medication errors should decrease. Next steps include expanding the intervention population and conducting sessions via telehealth to create more opportunities for caregiver-provider contact and to reinforce education.  Funding: Funded through Delivery System Reform Incentive Payment (DSRIP) and Clavin Family Education Fund.