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CompletedNCT01854151Updated May 17, 2024

Promoting Safe Use of Pediatric Liquid Medications

An interventional study of New Labeling/Dosing Strategy in Medication Errors, sponsored by NYU Langone Health. Completed at 4 sites in United States. Open to participants aged Up to 8 Years, including healthy volunteers. Per ClinicalTrials.gov, last updated 2024-05-17.

Sponsored by NYU Langone Health · Not applicable, Interventional, and Health services research

Phase
Not applicable
Study type
Interventional
Enrollment
1,005
Allocation
Randomized
Ages
Up to 8 Years
Sex
All
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Study summary

Variable and poor-quality drug labeling has been cited as a leading cause of medication errors and adverse drug events, especially in the context of low health literacy. This is a particularly important issue in pediatrics as more than half of US children are exposed to one or more outpatient medications in a given week, and studies suggest that over half of caregivers make errors when dosing liquid medications for children. Our study objective is to identify evidence-based strategies for labeling and dosing prescription and over-the-counter pediatric liquid medications in order to promote safe, appropriate use, as well as to inform state and federal policy standards. We hypothesize that a health literacy-informed labeling and dosing strategy will result in improved parent ability to administer medications prescribed to their young children.

Read the detailed description

Administering pediatric medications is frequently a difficult task for parents, in large part due to reliance on liquid formulations requiring the use of confusing, and often complex, measurement devices. Use of different units of measurement (milliliter, teaspoon, and/or tablespoon units) with variations in associated abbreviations, and the variability of measuring devices (type, markings, capacity), are sources of parent confusion. Low health literacy is linked to caregiver misunderstanding. Despite high error and utilization rates for outpatient pediatric medications, research examining strategies to prevent medication errors have focused largely on adults and on inpatient populations.

The ability to understand pediatric medication instructions is a critical health literacy and patient safety concern. Recently, the US Food and Drug Administration recognized the importance of this issue and released new guidelines to promote improved labeling and measuring devices for pediatric liquid medications. While these recommendations are an essential first step, evidence is needed to support the development of 'best practices' for designing optimal instructions and devices, especially for parents with limited literacy and/or limited English proficiency.

Our study objective is to identify evidence-based 'best practices' for labeling and dosing prescription and over-the-counter pediatric liquid medications in order to promote safe, appropriate use. A series of experiments will first be conducted to examine the efficacy of specific dosing and measurement strategies for improving parent understanding and use of pediatric liquid medications, including examining the impact of milliliter-only label instructions and devices, as well as the potential role for pictographic dosing diagrams. Findings will be merged with existing evidence-based health literacy 'best practices' for medication labeling to develop a comprehensive, patient-centered strategy for the labeling and dosing of pediatric liquid medications. The effectiveness of the patient-centered strategy will then be evaluated as part of a randomized controlled trial among English and Spanish-speaking parents whose children have been newly prescribed oral liquid antibiotics in a pediatric emergency department setting. Secondary aims of the study include extending the body of literature on health literacy and pediatric medication use, and generating a policy road map for achieving and implementing labeling and dosing standards for pediatric liquid medications.

02

Conditions studied

  • Medication Errors

Keywords

  • Medication errors
  • Medication dosing
03

In context

Lead sponsor

NYU Langone Health is the lead sponsor of 1,421 studies on the registry; 254 are open to participants now.

Of its 231 completed or terminated interventional studies of FDA-regulated products, 195 (84%) have results posted.

Counted across the registry records on this site, refreshed daily.

04

Who can participate

Ages eligible
Up to 8 Years
Sexes eligible
All
Accepts healthy volunteers
Yes

Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.

Phase II of Study (Effectiveness Trial)

Inclusion criteria

Inclusion Criteria:

  • parent/legal guardian of a child age 8 or less
  • parent/legal guardian age 18 or greater
  • child presenting for care in the emergency department
  • child prescribed short course liquid antibiotic
  • parent English or Spanish-speaking
  • parent responsible for administering medication to child

Exclusion criteria

Exclusion Criteria:

  • parent visual acuity worse than 20/50 (Rosenbaum Pocket Screener)
  • parent with uncorrectable hearing impairment
  • prior participation in study involving medication dosing
05

Study design

Phase
Not applicable
Primary purpose
Health services research
Allocation
Randomized
Intervention model
Single group
Masking
None (open label)
Enrollment
1,005 participants (actual)

Study arms

  • No intervention
    Standard Practice

    Parents whose children are prescribed medication and meet inclusion/exclusion criteria will fill their medication at their regular pharmacy and receive medication with labeling and dosing instruments as per routine

  • Experimental
    New Labeling/Dosing Strategy

    Parents whose children are prescribed liquid medication and meet inclusion/exclusion criteria will receive medications with health literacy informed labels and dosing instruments

    Other: New Labeling/Dosing Strategy

Interventions

  • OtherNew Labeling/Dosing Strategy

    Parents whose children are prescribed liquid medication will receive medications with health literacy informed labels and dosing instruments

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What researchers measure

Primary outcomes

  1. Medication dosing accuracy

    Time frame: Target within 2 weeks after medication course completion

07

Study locations

4 sites
  • Stanford University School of Medicine
    Stanford, California 94305, United States
  • Emory University School of Medicine
    Atlanta, Georgia 30303, United States
  • Northwestern University
    Chicago, Illinois 60611, United States
  • New York University School of Medicine
    New York, New York 10016, United States
08

References and documents

Publications

  • Yin HS, Parker RM, Sanders LM, Dreyer BP, Mendelsohn AL, Bailey S, Patel DA, Jimenez JJ, Kim KA, Jacobson K, Hedlund L, Smith MC, Maness Harris L, McFadden T, Wolf MS. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics. 2016 Oct;138(4):e20160357. doi: 10.1542/peds.2016-0357. Epub 2016 Sep 12. PubMed 27621414 ↗
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Updates

Tracking since Sep 25, 2026
No changes since tracking began. The registry record was last updated on May 17, 2024, before this site started recording changes on Sep 25, 2026. Its history is on ClinicalTrials.gov ↗
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Registry details

Key details

Study ID
NCT01854151
Lead sponsor
NYU Langone Health
Responsible party
Sponsor
First posted
May 15, 2013
Start date
Apr 22, 2013
Primary completion
Mar 25, 2019
Completion
Mar 25, 2019
Last update
May 17, 2024

Study contacts

H. Shonna Yin, MD, MS
principal investigator · NYU School of Medicine / Bellevue Hospital Center

Oversight

Data monitoring committee
Yes
FDA-regulated drug
No
FDA-regulated device
No
View the source record on ClinicalTrials.gov ↗

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This study is completed, as verified in May 2024. You cannot join it, but the record below documents what was studied.

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