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The Role of Health Literacy in Patient Safety

Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009 
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Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.

More than 77 million adults in the United States possess limited health literacy skills and will likely encounter difficulties interpreting and acting upon health information.(2) Specifically, limited health literacy has been repeatedly linked to problems with the use of preventive services, delayed diagnoses, understanding of one's medical condition, adherence to medical instructions, self-management skills, health status, and greater mortality risk.(3,4) It is estimated that these health literacy problems cost the U.S. health care system between $106 and $238 billion annually.(5)

Despite the high prevalence and ramifications, few health care providers or organizations are adequately responding to this issue at a time when patients and families are contending with ever greater health care roles and responsibilities. In ambulatory care settings, the patient or caregiver is increasingly being asked to assume oversight of quality control for implementing medical instructions and making routine health decisions. As such, there are many patient safety concerns that stem from whether health information was adequately communicated (or even made available) to patients and subsequently understood for appropriate follow-up.

Perhaps the most frequently noted safety issue connected to limited health literacy is the risk of medication errors that result from improper dosing administration.(6) Numerous studies have found low health literacy to be significantly associated with a poorer understanding of medication names, indications, and instructions and adherence to treatment regimens.(3,6,7) This current and well-publicized body of research has focused on the ability of patients to read, understand, and demonstrate prescription drug instructions. Prior studies have estimated that nearly half of adults misunderstand common dosing schedules (e.g., take two tablets by mouth twice daily) and auxiliary warnings (e.g., Do not chew or crush, swallow whole; for external use only) that detail important information to support safe and effective use.(7,8)

However, whether the context is giving an accurate and complete medical history, administering an over-the-counter medication, using a medical device, or reviewing nutritional information, concerns for patient safety and risk of medical error are significant in other scenarios in which a patient is inadequately informed yet must perform self-care activities.(9) Health care providers rely on patients to be capable, motivated partners who share responsibility in the delivery of safe and effective care.

Helping Patients Understand and Act

It is essential for health systems, health care professionals, and policy makers to develop a comprehensive response to the health literacy challenge and help patients and families better understand and act for the good of their or a loved one's health. Currently, a number of health literacy "best practices" have been recommended by the American Medical Association (AMA), American College of Physicians Foundation, and the Joint Commission to help clinicians better communicate with patients and families. Beyond the health care encounter, evidence-based recommendations have also been developed to improve consumer information materials, such as prescription drug labeling, to promote comprehension and ultimately adherence to recommended health actions as part of larger patient safety efforts.(1,6,10)

Improving Patient–Provider Communication

To confirm patient understanding of medical conditions, treatments, or other courses of action, health care providers are advised to use simple and concise language with patients and to apply certain communication methods, such as the "teach-back" or "teach-to-goal" technique.(10,11) In this manner, potential errors or adverse events, which might be the result of patient misinterpretations, can be identified, corrected, and hopefully avoided. Providers should limit the initial amount of information they provide to patients to the essentials, focusing on only two or three instructional points at a time. Additional content can be reviewed after this core knowledge has been successfully digested, while confirming at each step that the patient correctly processed the information. In general, health care encounters should promote discussion between the provider and patient, and patients must feel empowered to ask questions or voice concerns. For patients with chronic conditions, health care providers should review key self-care activities and verify that patients are performing health behaviors correctly via demonstration.

Enhancing Health Materials

Improving the readability of health materials is also needed. Print brochures and leaflets, as well as information delivered by video or the Internet, can all help support patients and families in retaining health knowledge after they have left the physician's office or hospital. In some instances, written instructions may become the only means by which patients and families learn about important health instructions.(6,9) For example, prior research has found that physicians and pharmacists frequently miss opportunities to adequately counsel patients on how to safely administer prescribed medication regimens.(12) As a result, the clarity of prescription container label and supplementary patient information leaflets becomes even more salient. Health systems must take added steps to ensure that print and other multimedia communications (i.e., Internet, video, etc.) use plain language, limit and layer content, and follow an organizational structure that makes sense to the target audience: patients and families.

Building a Safe, Patient-Centered Health Practice

Addressing health literacy concerns as part of a patient safety agenda must extend beyond provider communication skills and enhanced health materials. It should also more broadly address the way we deliver health care. Health information must be communicated clearly, concisely, consistently, and in a timely way, but there should also be constant opportunities for feedback between providers and patients. The challenge to health care practices and systems alike will be to find ways to have sustainable processes in place to routinely identify and track patients who may be struggling to properly comply with medical instructions, or who may benefit from educational interventions.


Strategies to promote health literacy by helping patients more easily obtain, process, and understand health information to be able to make informed decisions ultimately supports patient safety. The health system must promote better communication of health information while also simplifying the demands it places on patients. However, patients and families must also recognize their roles and responsibilities to be informed and vigilant in protecting their health. A safer health care environment can only be achieved if patients are included as active participants and health care providers and systems clearly communicate their expectations.

Michael S. Wolf, PhD, MPHAssistant Professor of Medicine and Learning Sciences Director, Center for Communication in HealthcareInstitute for Healthcare Studies Division of General Internal Medicine Feinberg School of MedicineNorthwestern University

Stacy C. Bailey, MPHProgram Director, Health Literacy and Learning Program Institute for Healthcare StudiesNorthwestern University


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1. The Joint Commission. What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The Joint Commission; 2007. [Available at]

2. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. US Department of Education. Washington, DC: National Center for Education Statistics; 2006. Report No: NCES 2006-483. [Available at]

3. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228-1239. [go to PubMed]

4. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167:1503-1509. [go to PubMed]

5. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. [Available at]

6. Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Standardizing Medication Labels: Confusing Patients Less, Workshop Summary. Washington, DC: National Academies Press; 2008. ISBN: 9780309115292.

7. Davis TC, Wolf MS, Bass PF 3rd, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145:887-894. [go to PubMed]

8. Davis TC, Wolf MS, Bass PF 3rd, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21:847-851. [go to PubMed]

9. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004. ISBN: 9780309091176.

10. Weiss BD. American Medical Association. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians, 2nd ed. Chicago, IL: American Medical Association Foundation and American Medical Association; 2007. [Available at]

11. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31:S96-S104. [go to PubMed]

12. Metlay JP, Cohen A, Polsky D, Kimmel SE, Koppel R, Hennessy S. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc 2005;53:976-982. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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