Pictogram-based instructions reduce home medication errors among pediatric caregivers: A randomized controlled trial.

Background: Medication errors with liquid pediatric formulations are a pressing patient safety concern. This study evaluated the effectiveness of a pictogram-based instruction package in reducing home medication errors made by caregivers compared with a text-based instruction label. Methods: This ra...

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Published in:Journal of Patient Safety & Risk Management Vol. 31; no. 4; pp. 182 - 190
Main Authors: Ong, Bee Yean, Hoo, Huei Yen, binti Borham, Nurul Shafiqah, Mohd Salleh, Nur Suhailah binti, Mohamed Saat, Sakinah binti, Panirselvam, Shalini
Format: research tables/charts randomized controlled trial Journal Article
Published: Sage Publications Inc. Jul2026
Online Access:View this record in EBSCOhost
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      dt: Jul2026
      vid: 31
      iid: 4
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      pub: Sage Publications Inc.
      place: Thousand Oaks, California
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        atl: Pictogram-based instructions reduce home medication errors among pediatric caregivers: A randomized controlled trial.
      aug:
        au:
          Ong, Bee Yean
          Hoo, Huei Yen
          binti Borham, Nurul Shafiqah
          Mohd Salleh, Nur Suhailah binti
          Mohamed Saat, Sakinah binti
          Panirselvam, Shalini
        affil: Department of Pharmacy, Hospital Enche' Besar Hajjah Khalsom, Kluang, Johor, Malaysia
      sug:
        subj:
          Medication Errors Prevention and Control
          Caregivers Education
          Drug Labeling
          Home Health Care
          Pediatrics
          Outcomes (Health Care)
          Malaysia
          Human
          Male
          Female
          Infant
          Adult
          Hospitals, Pediatric
          Randomized Controlled Trials
          Random Assignment
          Pretest-Posttest Control Group Design
          Comparative Studies
          Convenience Sample
          Antibiotics
          Self Report
          Pearson's Correlation Coefficient
          Chi Square Test
          T-Tests
          Mann-Whitney U Test
          Confidence Intervals
          Odds Ratio
          Data Analysis Software
          Descriptive Statistics
          Patient Preference
          Patient Safety
          Infant: 1-23 months
          Adult: 19-44 years
          Male
          Female
      ab: Background: Medication errors with liquid pediatric formulations are a pressing patient safety concern. This study evaluated the effectiveness of a pictogram-based instruction package in reducing home medication errors made by caregivers compared with a text-based instruction label. Methods: This randomized controlled trial (RCT) recruited 134 caregivers of children prescribed reconstitutable oral antibiotics using convenience sampling. Participants were randomly assigned to receive either pictogram-based instructions (intervention group) or standard text-only labels with verbal explanation (control group). Drug reconstitution errors were directly observed, while potential administration errors were self-reported. Caregiver label preferences were also evaluated. Outcomes between the groups were compared using Chi-square tests, and risk ratios (RR) were calculated to determine the intervention's effect size. Results: The pictogram-based intervention led to a significant reduction in medication errors. The intervention group (n = 69) had substantially fewer reconstitution errors compared to the control group (n = 65) (21.7% vs. 84.6%; risk ratios (RR) = 0.26, 95% confidence interval (CI): 0.16–0.41, p < 0.001) and fewer self-reported potential administration errors (8.7% vs. 84.6%; RR = 0.10, 95% CI: 0.05–0.22, p < 0.001). Notably, errors related to incorrect water volume and misinterpreted dosing intervals and duration were significantly reduced. Over 92% of caregivers in both groups expressed a strong preference for instructions combining pictograms with text, citing improved clarity and ease of understanding. Conclusion: In this RCT, a pictogram-based instruction package was a highly effective and simple risk management tool that significantly reduced caregiver medication errors. Its implementation is a promising strategy to enhance medication safety and adherence in diverse pediatric populations.
      pubtype: Academic Journal
      doctype:
        research
        tables/charts
        randomized controlled trial
        Journal Article
      ougenre: Article
    language: English
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