Avoiding risky business: supporting optimal home medication administration for children with cancer.

Abstract

Correct administration of medication at home to a child undergoing cancer treatment is critical to both curing the disease and minimizing adverse effects of treatment. The most common childhood cancer, acute lymphoblastic leukemia, relies on home administration of mercaptopurine, methotrexate, and corticosteroids for 2 or more years of treatment. Less than 95% adherence to nightly mercaptopurine administration during a 6-month period of observation was associated with a 2.5-fold increase in the risk of relapse compared with adherent patients. If this finding translates to other drugs and other diseases, strategies to maximize adherence will become a critical part of childhood cancer treatment. Walsh et al have already shown that medication errors in the home of children with cancer are common. If we consider the home setting carefully, we should not be surprised that there are challenges with both adherence and safety. Caregivers, usually parents, are expected to carry out a complex medication administration process in the home. These caregivers usually have far less education about medication and none of the tools to support performance provided for nurses giving medications in the hospital. Parents do not have medication administration records (updated each time a medication is added, changed, or discontinued) with prompts for each medication with a specific dose, route, and time of day or interval since last dose and records of doses given. We also ask parents to serve as pharmacists and ensure that only the correct medication products are available for administration. Parents of a child with cancer not only do not have such supports but also face additional challenges. A common approach to reduce medication error is to focus on the so-called five rights: the right patient, the right drug, the right dose, the right route, and the right time. Parents are highly likely to give the medication to the right patient since there is usually only one child with cancer in the home. Since the vast majority of home medications are given by the oral route, the odds are high that medications will be given by the right route. However, as shown in Table 1, there are many factors in the home that can decrease the probability of the right drug, the right dose, and the right time. Some of these issues are unique to pediatrics because they involve ability to swallow pills, potential poor cooperation with care, lack of availability of appropriate pill strengths for pediatric dosing, and issues related to parent as caregiver. One strategy to decrease error could be to focus on patient education about medication as in the 2014 Joint Commission National Patient Safety Goals, Stage 1 of the federal Meaningful Use criteria for electronic health records, and the American Society for Clinical Oncology/Oncology Nursing Society chemotherapy safety standards. Education alone, however, is likely insufficient to achieve reliable performance of a complex task such as medication administration in the home. In the article that accompanies this commentary, Walsh et al describe the development of a tool to support parents and other caregivers in the home to ensure that each child with cancer receives the right dose of the right drug at the right time via the right route. Walsh et al deserve kudos for this effort which includes a three-part product with a Web site for general information and decision-support tools, a communication guide to maximize understanding of information provided by caregivers, and a patientand cycle-specific medication calendar, available in a paper or electronic format. Critical to their work was the inclusion of the many parents who contributed to the design and testing of the final product. As the authors acknowledge, this is a preliminary effort whose impact has yet to be shown. Larger studies and studies at multiple centers are needed to determine if this specific strategy will decrease medication error in the home or if additional strategies will be needed. As the field of pediatric oncology moves forward, more work is needed to ensure parents of children with cancer have the exact supports needed for safe and reliable medication administration in the home in order to maximize cure and minimize harm.