Improving patient understanding of prescription drug label instructions.

Terry C. Davis; Alex D. Federman; Pat F. Bass; Robert H. Jackson; Mark Middlebrooks; Ruth M. Parker; Michael S. Wolf

Study

Improving patient understanding of prescription drug label instructions.

January 21, 2009

Davis TC, Federman AD, Bass PF, et al. J Gen Intern Med. 2009;24(1):57-62.

View more articles from the same authors.

This cross-sectional study conducted structured patient interviews and found that their understanding of prescription drug labels varied significantly. Patients with limited literacy experienced the greatest challenges, but use of precise wording did improve comprehension.

PubMed citation

Available at

Related Resources From the Same Author(s)

Misunderstanding of prescription drug warning labels among patients with low literacy.

June 7, 2006

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Low literacy impairs comprehension of prescription drug warning labels.

July 26, 2006

To err is human: patient misinterpretations of prescription drug label instructions.

November 7, 2007

Predictors of misunderstanding pediatric liquid medication instructions.

December 9, 2009

Improving prescription drug warnings to promote patient comprehension.

January 20, 2010

Patient-centered approach for improving prescription drug warning labels.

September 24, 2008

Helping patients simplify and safely use complex prescription regimens.

March 16, 2011

A patient-centered prescription drug label to promote appropriate medication use and adherence.

January 18, 2017

Risk of unintentional overdose with non-prescription acetaminophen products.

June 20, 2012

What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use.

August 14, 2013

Medication reconciliation and hypertension control.

March 24, 2010

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

December 8, 2010

Variability in pharmacy interpretations of physician prescriptions.

March 4, 2009

Visual acuity, literacy, and unintentional misuse of nonprescription medications.

June 13, 2018

Parents' medication administration errors: role of dosing instruments and health literacy.

February 10, 2010

Liquid medication errors and dosing tools: a randomized controlled experiment.

October 5, 2016

Limited health literacy is a barrier to medication reconciliation in ambulatory care.

October 31, 2007

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

May 31, 2017

Pictograms, units and dosing tools, and parent medication errors: a randomized study.

July 19, 2017

Preprinted order sets as a safety intervention in pediatric sedation.

February 25, 2009

Human factors in anaesthetic practice: insights from a task analysis.

March 19, 2008

Motivational influences on anaesthetists' use of practice guidelines.

May 13, 2009

Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Framework.

December 21, 2005

A concept analysis of undergraduate nursing students speaking up for patient safety in the patient care environment.

August 3, 2016

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

"At home, with care": lessons from New York City home-based primary care practices managing COVID-19.

December 16, 2020

Lehigh Valley Hospital: engaging patients and families.

October 12, 2005

Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use.

April 15, 2009

Development of the pharmacy safety climate questionnaire: a principal components analysis.

March 11, 2009

Adverse drug events and medication problems in "Hospital at Home" patients.

October 10, 2018

Walking the plank: an experimental paradigm to investigate safety voice.

July 31, 2019

Adverse event rates as measures of hospital performance.

September 21, 2011

Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference.

November 28, 2012

The effect of visitation restrictions on ED error.

March 6, 2024

A prevalence study of errors in opioid prescribing in a large teaching hospital.

August 10, 2011

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016.

October 10, 2018

An IDEA: safety training to improve critical thinking by individuals and teams.

April 10, 2019

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

January 8, 2014

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

May 7, 2014

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution.

March 31, 2010

Measurement of adverse events using "incidence flagged" diagnosis codes.

February 8, 2006

The incidence and cost of adverse events in Victorian hospitals 2003-04.

June 28, 2006

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study.

March 6, 2005

In-home medication reviews: a novel approach to improving patient care through coordination of care.

May 11, 2011

The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture.

March 20, 2024

Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.

August 20, 2008

Cognitive versus technical debriefing after simulation training.

April 12, 2006

Predictors of healthcare professionals' attitudes towards family involvement in safety-relevant behaviours: a cross-sectional factorial survey study.

October 15, 2014

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.

May 17, 2006

The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.

June 21, 2023

The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support.

December 22, 2010

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

January 26, 2022

Impact of a pharmacotherapy alerting system on medication errors.

January 23, 2013

Persistent opioid use among pediatric patients after surgery.

December 20, 2017

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

The variability and quality of medication container labels.

September 19, 2007

An exploratory study measuring verbal order content and context.

June 10, 2009

A safety culture transformation: its effects at a children's hospital.

September 12, 2012

Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes.

May 11, 2016

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

A vision for patient-centered health information systems.

January 26, 2011

Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists.

October 24, 2007

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes.

May 25, 2016

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.

July 2, 2008

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.

May 31, 2006

Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.

November 16, 2005

Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.

March 22, 2017

The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.

February 14, 2018

Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study.

June 9, 2010

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

January 13, 2010

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.

September 26, 2012

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.

February 20, 2008

Establishing a simulation center for surgical skills: what to do and how to do it.

September 12, 2007

Resolving the productivity paradox of health information technology: a time for optimism.

June 6, 2018

Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach.

May 11, 2016

Intra-operative monitoring—many alarms with minor impact.

September 18, 2013

Checklists to reduce diagnostic errors.

February 9, 2011

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts.

August 29, 2012

Profiles in patient safety: a "perfect storm" in the emergency department.

June 20, 2007

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

June 7, 2017

Serious experience events: applying patient safety concepts to improve patient experience.

July 6, 2022

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

July 22, 2009

Measuring and managing quality of surgery. Statistical vs incidental approaches.

March 6, 2005

A novel approach to implementation of quality and safety programmes in anaesthesiology.

December 7, 2011

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.

May 18, 2016

How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.

April 16, 2008

Applying human factors engineering to address the telemetry alarm problem in a large medical center.

August 11, 2021

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

Quantitative assessment of workload and stressors in clinical radiation oncology.

June 13, 2012

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?

November 18, 2009

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

August 11, 2010

Electronic health record adoption and rates of in-hospital adverse events.

February 24, 2016

Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.

February 15, 2012

Related Resources

Patients with low health literacy make more errors interpreting instructions and warnings.

December 13, 2023

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement.

November 8, 2023

Medication adverse events in the ambulatory setting: a mixed-methods analysis.

October 26, 2022

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

May 11, 2022

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.

October 1, 2021

Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults.

June 30, 2021

WebM&M Cases

Multiple Levels Involved in Prescribing the Wrong Medication

September 30, 2020

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.

April 17, 2019

Visual acuity, literacy, and unintentional misuse of nonprescription medications.

June 13, 2018

AHRQ Health Literacy Universal Precautions Toolkit. 2nd edition.

July 1, 2015

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.

February 26, 2014

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

Findings and Lessons From the AHRQ Ambulatory Safety and Quality Program.

December 18, 2013

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

The effects of electronic prescribing by community-based providers on ambulatory medication safety.

December 4, 2013

Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.

November 6, 2013

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

September 11, 2013

Impact of individual and team features of patient safety climate: a survey in family practices.

August 14, 2013

Safety climate and its association with office type and team involvement in primary care.

May 29, 2013

Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.

March 27, 2013

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

October 31, 2012

The relationship of self-report of quality to practice size and health information technology.

October 10, 2012

Are health professionals' perceptions of patient safety related to figures on safety incidents?

September 19, 2012

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing.

August 1, 2012

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

June 27, 2012

Medication reconciliation campaign in a clinic for homeless patients.

April 4, 2012

Medical errors reported by French general practitioners in training: results of a survey and individual interviews.

April 4, 2012

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

March 21, 2012

Emotional impact of patient safety incidents on family physicians and their office staff.

March 21, 2012

See More About The Topic

Ambulatory Clinic or Office

Health Care Providers

Family Medicine

Primary Care

General Internal Medicine

Improving patient understanding of prescription drug label instructions.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving patient understanding of prescription drug label instructions.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site