Pediatric Medication Safety: A Modified American Academy of Pediatrics Policy Statement

Emily A. Chapski, Dr. April H. Choi, and Dr. Ashley D. Hastings and Dr. Shannon DaSilva

Doctor of Nursing Practice Project at Baylor University;

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Abstract

Medication errors in the home setting pose a significant risk to pediatric patients¹. The American Academy of Pediatrics (AAP) provided a comprehensive policy statement to address medication safety concerns in children in the home setting. A 90-day quality improvement (QI) project based on the AAP policy statement was implemented at Peekaboo Pediatrics, Ascension Lockhart, and Santa Teresa Pediatric clinic for parents of children aged six months to two years old. Data collection was completed through chart audits and direct observation. This Doctor of Nursing Practice (DNP) project included       1,439 pediatric patients across three clinics with objectives that aligned with the AAP policy statement. Main objectives include provider documentation of medication education and the provision of oral dosing syringes with a medication dosing chart. This DNP project highlights the importance of collaborative effort in pediatric primary care settings for preventing home medication errors.

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Pediatric Medication Safety

Background

Medication errors in home settings pose a significant concern in pediatric care¹. Nearly 50% of children experience unintentional home medication errors due to misinterpretation of dosing instructions¹. It is projected that every eight minutes, a child experiences an at-home medication administration error in the United States². This equates to roughly 46,000 children six years and younger admitted to the emergency department for unintentional medication overdoses, with 5% of these cases resulting from parental administration errors due to overdosing or underdosing³. While specific medications remain anonymous, 41% of these overdoses involved prescription medications, and 28% involved over-the-counter medications³.

Yin et al. (2021) found that medication administration for infants and toddlers is especially challenging for parents due to the need for weight-based dosing conversions, which increase the risk of medication errors. The most common over-the-counter medications, Acetaminophen (Tylenol) and Ibuprofen (Advil, Motrin), have different dosing requirements and durations of action⁴. For example, Tylenol requires 10-15 mg/kg every 4 to 6 hours as needed, whereas Motrin requires 10 mg/kg every 6 to 8 hours as needed, which can be challenging for parents to remember^5,6. The lack of standardized dosing tools for liquid medication can increase medication dosing errors in children¹. These are some of the challenges that can lead to unintentional medication dosing errors when parents administer medications at home. 

National Guidelines

In response to this growing concern, the American Academy of Pediatrics (AAP), which comprises the largest group of pediatric providers, issued a robust policy statement with 24 comprehensive recommendations and strategies for standardizing safe medication administration education for parents⁵. This Doctor of Nursing Practice (DNP) quality improvement (QI) project adopted 15 of the 24 AAP recommendations to be implemented at three pediatric primary care clinics. The 15 recommendations were selected based on their relevance to the pediatric primary care setting and feasibility within the specialty while ensuring practical application during routine pediatric visits. The 15-AAP recommendations include clear communication with parents, demonstrating the use of standardized oral dosing syringes, including the child’s weight on all prescribed medications, educating parents on safe administration of medication, safe storage of medications, and safe disposal of expired medications¹.

The Pediatric Safe Medication Checklist (Figure 1) is a five-item tool to remind providers to apply the 15-AAP recommendations. The checklist focused on Tylenol and Motrin because these two medications are commonly used in pediatric care⁴. The checklist streamlines key practices into patient workflows during the 90-day implementation period through the provision of standardized dosing tools, plain language, education strategies, and documentation to support continuity of care. These steps align with the AAP policy statement recommendations and help facilitate provider compliance.

Figure 1: Provider Checklist

Purpose Statement

This DNP project was conceptualized in response to the lack of process and inconsistent delivery of medication education across the three pediatric clinics, according to communication with the pediatric providers. The purpose of this DNP project was to use the provider checklist (Figure 1) as a reminder of the 15-AAP recommendations to assist providers in delivering concise medication safety education to parents. The 15 recommendations were adopted from the AAP policy statement with a focus on clear and concise communication, provision of oral medication dosing tools to help parents deliver precision medication dosing, weight-based dosing guidelines (in mg/kg) with the medication dosing chart, safe medication storage, and proper disposal of expired medications to improve pediatric medication safety at home.

Implementation Setting

The DNP project was implemented across three pediatric clinics. Peekaboo Pediatrics of Houston, TX is a family-owned private practice with Medical Doctors (MDs), one Pediatric Nurse Practitioner (PNP), and two nursing support staff. Ascension Lockhart Pediatric Clinic in Lockhart, TX, is part of the Seton Hospital organization, comprises of a MD and two support nursing staff. Santa Teresa Children’s Clinic in Santa Teresa, NM, is an outpatient pediatric clinic managed by a group of MDs and PNP. All three pediatric clinics offer acute care and routine well-child care from birth to late adolescence while serving a predominantly Hispanic/Latino population. The mission of the three clinics is to deliver compassionate care to vulnerable populations while improving the health, wellness, and safety of the children within the communities. This common mission among the three clinics helps solidify the importance of this DNP project. 

Quality Improvement

This DNP project followed the QI methodology over 90 days to improve safe medication education in the pediatric clinics. The Knowledge-to-Action (KTA) framework is utilized for this DNP project because it provides a systematic approach to translating a QI project into action^7,8, and the Plan-Do-Study-Act (PDSA) framework was selected because it is frequently used in healthcare to improve an existing process⁹.

Figure 2: FOCUS-PDSA processes⁹

The stages of PDSA are “Plan,” “Do,” “Study,” and “Act.” This DNP project completed two 45-day cycles of the PDSA. The first cycle occurred within the first 45 days of the implementation, and the second 45-day cycle occurred after assessing the effectiveness of the interventions and adjusting the implementation as needed. Within each 45-day cycle, the student leads would gather recommendations from the clinic staff and parents during the first PDSA cycle and implement the adjustments during the second PDSA cycle. The Gnatt Chart (Figure 3) depicts the specific stages of the PDSA cycles.

Figure 3: Gnatt Chart

Project Procedures

Confidentiality and IRB Approval

The student leads were responsible for patient confidentiality to ensure no harm was inflicted throughout this project. Confidentiality was achieved, and strict Health Insurance Portability and Accountability Act (HIPAA) compliance was enforced. This was accomplished by removing all patient and family identifiers. Additionally, patient documentation and charts remained within the clinic premises and were never removed from the clinic. Clinic-approved language translation support was utilized for Spanish-speaking parents to minimize potential language barriers.

Exemption status from the Institutional Review Board (IRB) at Baylor University and approval from Ascension Lockhart’s research department were obtained. IRB approval was not required from Peekaboo Pediatrics and Santa Teresa Children’s Clinic. The Ascension IRB required the student lead to complete an online Collaborative Institutional Training Initiative (CITI) on human subjects and submit all preliminary DNP documents to the research panel to ensure the protection and ethical treatment of human subjects in research before the start of the DNP project¹⁰.

Inclusion Criteria and Sample Size.

The inclusion criteria for this DNP project were defined as pediatric patients aged six months to two years old due to the increased frequency and recommendations of well-child visits. The goal was to include as many patients aged six months to two years old during the 90-day implementation period. The exclusion criteria were children outside of this age bracket and children with chronic medical complexities.

Project Implementation

The implementation team included the student lead, pediatric providers, and clinic staff. The materials for the implementation of this DNP project included 5 mL oral medication dosing syringes and paper copies of pediatric Tylenol/Motrin medication dosing charts (Figure 4). Due to the large Hispanic population, each clinic had both English and Spanish medication dosing charts readily available for parents. Each clinic started with 200 dosing syringes and 200 Tylenol/Motrin medication dosing charts. As each week progresses, the total number of remaining dosing syringes and medication dosing charts is subtracted from the original 200 count.

Figure 4: Project Resources – 5 mL Liquid Dosing Syringe and Dosing Chart

Before project implementation, the clinic staff at each pediatric clinic would receive education that aligned with the AAP policy statement to ensure consistent implementation across all three sites. Student leads emphasized the use of oral dosing syringes, distribution of a weight-based Tylenol/Motrin dosing chart, and a safe medication administration checklist for providers during clinic visits. Communication strategies included using fourth-grade level language, avoiding medical jargon, and employing repeat-back methods to confirm parental understanding. Visual aids, such as the dosing chart and oral syringes, were incorporated to support comprehension and proper medication administration at home. A hard copy of the AAP policy statement was provided to the clinic staff and kept at the clinic for reference and to help guide the process of delivering medication education to parents.

Project Objectives

The first objective is to advise 100% of the pediatric providers and clinic staff members on incorporating the AAP policy statement on safe home medication administration. The second objective involved provider discussion and documentation of safe medication use with parents of children aged six months to two years old 80% of the time. The third objective was to distribute oral medication dosing syringes with weight-based Tylenol/Motrin medication dosing charts to 80% of the parents.

Data Collection Methodology

Data were collected through patient chart audits and direct observation. Chart audits assessed compliance with dosing syringe and medication chart distribution and documentation of the provider checklist, with the oversight of the student leads, to ensure accuracy and consistency. The data were obtained from patients’ visit summaries and providers’ documentation of safe medication education in the electronic health record (EHR). Biweekly inventory checks were recorded for the dosing syringes and medication dosing charts. This number was subtracted from the original 200-count. The project leads were responsible for restocking the oral dosing syringes in each patient room. Labeled storage bins containing oral dosing syringes and folders containing the medication dosing charts were designated strictly for this project. These safekeeping measures accurately track the number of oral dosing syringes and medication charts distributed throughout the DNP project.

Evaluation

This Pediatric Medication Safety DNP project analyzed both process indicators and patient-sensitive outcomes to assess the effectiveness of implementing the selected AAP medication safety recommendations in three pediatric primary care clinics. The process measures included staff education completion, provider documentation compliance, and the distribution of dosing syringes and handouts for Tylenol and Motrin dosing. Each clinic maintained staff training documentation and chart audits to assess the frequency of medication education documentation during visits for children aged six months to two years old. Supplies used for the DNP projects were labeled and stored separately from other clinic supplies to prevent accidental misuse. The evaluation process ensured that key objectives were addressed and adjustments were made during the project's two PDSA cycles.

Patient-sensitive outcomes focused on the delivery of consistent medication education using teach-back, plain language strategies, and the provision of standardized dosing tools to parents. Data collection includes EHR audits and manual inventory logs of the oral dosing syringes and the medication dosing charts. Student project leads at each clinic were responsible for conducting the education sessions, collecting data, and performing chart reviews. Descriptive statistics were used to summarize the outcomes, frequencies, and percentages. Given the project’s small sample size and QI nature, inferential statistical testing was not necessary.

Project Results

The first objective of educating 100% of the pediatric providers and clinic staff at Ascension Lockhart, Peekaboo Pediatrics, and Santa Teresa Children’s Clinic on selected AAP recommendations was achieved. This objective was met through a student-led breakfast or lunch and learning session. This objective was easily attainable because healthcare providers are innately interested in improving the overall health of their patients.

The second objective was to ensure pediatric providers documented safe medication education at least 80% on all clinic visits. The overall data for all three sites for this objective was only 5.1% (n= 74 out of 1,439 patients aged six months to two years old). Ascension Lockhart recorded 228 visits of which 14.9% (n=34) of the visits had documented medication education in the patient’s visit summary. Peekaboo Pediatrics recorded 1,047 visits of which 0.6% (n= 10) of patients received the full intervention. Santa Teresa Children’s Clinic had 164 eligible visits, with 18.3% (n=30) including medication education documented in the patient’s EHR. This data revealed that provider documentation of the medication safety education fell significantly short of the desired 80% compliance. Before this DNP project implementation, this data was not collected at any of the three pediatric clinics. Thus, even with a small margin of 5.1% documentation, this is a slight improvement from the baseline of zero or minimal medication education documentation in the EHR.

The third objective was to distribute oral dosing syringes and Tylenol/Motrin medication dosing charts to at least 80% of the parents with children aged six months to two years old during all visits. The overall data from the three clinics (n= 1439) showed the oral dosing syringes had better distribution rates (n= 346, 24.0%) (Table 1) compared to Tylenol/Motrin medication dosing charts (n= 311, 21.6%) (Table 2). While this objective did not achieve the desirable 80% goal, meaningful progress was made. Peekaboo Pediatrics distributed 100 oral syringes and medication dosing charts, with a distribution rate of 9.6%. Ascension Lockhart distributed 134 oral dosing syringes with a distribution rate of 58.8% and 99 medication dosing charts with a distribution rate of 43.4%. Santa Teresa Children’s Clinic distributed 112 oral syringes and medication charts with a 68.3% distribution rate. The slight difference in the distribution between the dosing syringes and the medication dosing chart at Ascension was due to some parental preference for a digital version of the medication dosing chart. This slightly affected the overall paper medication dosing chart distribution.

Table 1: Syringe Distribution Between Pediatric Clinics

Table 2: Medication Dosing Chart Distribution

Discussion: Strengths and Limitations

Home medication errors in pediatric patients are an unfortunate but common occurrence¹. Factors contributing to at-home medication errors include inconsistent medication education from providers, confusing weight-based dosing for parents, lack of correct oral medication dosing tools, and potential language barriers^1,2. The above factors are what prompted the implementation of a modified AAP policy statement on the pediatric medication safety project.

The strengths of this DNP project include leveraging a robust AAP policy statement, which provides a solid foundation for this DNP project. The practical use and adaptability of the AAP recommendations translate seamlessly into three pediatric clinical practices and increase the generalization of the interventions. Key stakeholders' engagement and the pediatric clinic's approval to complete the DNP project were positive attributes to the DNP project. Pediatric providers' agreement with the AAP policy statement enabled providers to be more open to change in the clinic setting, the DNP project, and awareness of how medication education is delivered to parents. The modified AAP recommendations streamline the parental medication education process at the three pediatric clinics that did not exist prior to this DNP project. Interdisciplinary collaboration between pediatric providers, nursing staff, and student leads greatly benefited the patients’ health outcomes through improved medication safety communication, shared patient-centered health goals, and care coordination⁵.   

The family-centered approach using simple phrases, utilizing language translation support in patients’ native language, providing visual guides, and oral dosing syringes as measuring devices, enhanced the parents' overall understanding. Additionally, the use of English or Spanish medication dosing charts improved understanding for parents of Hispanic ethnicity. The above strategies ensure patients and parents have a shared partnership in the health and well-being of the patient and strengthen the goal of a family-centered approach⁵. Parents’ overall interest and attitude towards medication safety education were positive. While parental attitude was not measured, verbal exchanges between parents and nursing staff at Ascension Lockhart found that the parents expressed gratitude for the Tylenol/Motrin weight-based medication chart. Some parents opted to take a picture of the medication dosing chart to keep a digital copy on their personal phone in addition to the paper printout. Parents who elected to take a digital copy of the medication dosing chart were not counted towards the overall clinic distribution of paper dosing chart.

Limiting factors for this DNP project included a short implementation period. The short 90-day implementation period presents inherent limitations for a clinical process change that aligns with the objectives of the project. Health-related QI projects often span months to years, depending on the complexity and size of the project, for process change to be of statistical relavance⁸. Unforeseen clinic staff turnover at Peekaboo Pediatrics and Ascension Lockhart hindered the success of this DNP project because it shifted the clinic and project responsibilities to the remaining staff members¹¹. This resulted in some inconsistency and discontinuity of the project implementation among the remaining staff memebers¹¹.

Provider time limitations also greatly impacted the success of this DNP project. Depending on the pediatric clinic, the average patient visit is 18 minutes, with slightly more time allotted for new patients and medically complex patients¹². This time is spent on reviewing charts, reviewing recent laboratory results, discussing the patient’s new chief complaint, conducting a physical exam, and formulating a treatment plan. With an increased patient load, provider documentation of the medication safety education provided to parents was likely inconsistent due to time constraints. Peekaboo Pediatrics had the high patient volume (n=1,047) but had some inconsistencies in provider documentation of medication safety education, distribution of the dosing syringes, and medication dosing charts. This is likely attributed to the increased acuity of the patients, the limited amount of time providers spend with each patient, and the increased demand of the providers to chart, review labs and x-rays, send prescriptions, and return phone calls and messages.

While meaningful progress was made in implementing this DNP project, student-driven projects are challenging to implement. Not only are clinic staff members tasked with their own responsibilities in the pediatric clinic, but this DNP project may be viewed as extra tedious work that they will not be compensated for. Additionally, student leads who are not present at the clinic every week had inconsistent distribution of syringes and medication charts. Although there were many strengths while implementing this DNP project, the limitations included short implementation duration, clinic staff turnover, provider time constraints, and the inability of the student lead to oversee daily operations negatively affected the outcomes of the DNP project.

Conclusion and Recommendations

Over-the-counter medications such as Tylenol and Motrin are safe for children, but misuse can still lead to serious health issues. Five percent of all unintentional medication errors for children six years and younger are related to parental misdosing³. These statistics prompted the implementation of the DNP project to address pediatric medication safety concerns in the home setting. Based on the data collected at Ascension, Peekaboo Pediatrics, and Santa Teresa, student leads were successful in increasing awareness of the AAP policy statement among providers. Objective two of provider documentation of medication education in patient’s EHR and objective three of distribution of oral dosing syringes and medication dosing chart were not entirely successful in meeting the predetermined 80% benchmark. Although this DNP project fell short of the goal, this DNP project was meaningful because no process was in place to guide providers on how to best deliver medication safety education to parents. Barriers such as student-driven projects, the unforeseen clinic staff turnovers at two of the three clinics, and time constraints negatively impacted the overall success of this DNP project.

Future efforts and projects related to the AAP policy statement should extend the QI project over several months to allow for a process change to take place within an organization. Optimization of the EHR system to prompt providers to document medication education as part of their patient visit summary charting may increase overall compliance. Embedding an electronic version of the medication dosing chart within the patient’s EHR may increase parental access to reliable information regarding correct medication dosing¹³. Lastly, broadening the medication education to all pediatric age groups is critical because dosing errors can occur in all age groups. Although this DNP project fell short of its objectives and goals, it highlights the importance of collaborative work among the pediatric clinic and parents to provide a family-centered approach to address medication safety in the pediatric population. This modified version of the AAP policy statement is a strong foundation and baseline for future QI projects regarding medication safety education in the pediatric clinic setting.

Acknowledgments

The student leads and authors of this project would like to extend their gratitude to the pediatric clinics, pediatric provider, clinic staff members, DNP faculty chair and author, Dr. DaSilva, and Baylor University Statistician, Dr. Ke. The ideas formulated in this manuscript belong to the student leads and authors and do not represent the views of the pediatric providers or the clinics.

Funding Source

The funding for this DNP project was equally shared among the student leads and authors.

Abbreviations:

AAP

American Academy of Pediatrics

DNP

Doctor of Nursing Practice

EHR

Electronic Health Records

PDSA

Plan-Do-Study-Act (PDSA)

QI

Quality Improvement

References

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Appendix A: Site Letter of Support

Appendix B: DNP Project Proposal Approval Form