… J Pediatr Intensive Care … Preventable harm continues to … care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported …

Prior research has shown that patients with limited health literacy are at increased risk for misunderstanding the appropriate dosing of acetaminophen, a commonly used nonprescription medication that can cause acute liver failure after an overdose. In this study, researchers examined the risk of nonprescription acetaminophen misuse among 500 English-speaking patients across 4 outpatient clinics. They found that 39% of participants had limited health literacy and 54% had low visual acuity. Both reduced visual acuity and lower health literacy were independent risk factors for dosing errors and for insufficient understanding regarding the simultaneous use of multiple acetaminophen-containing products. An AHRQ Literacy Toolkit is available that provides a business case for interventions, educational tools, and guides for engaging patients in health literacy discussions. A previous WebM&M commentary discussed an incident involving confusion with acetaminophen dosing.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Safer opioid prescribing requires …

… of liquid medications to children. Two of the coauthors, Michael S. Wolf and Stacy C. Bailey, described the implications of …

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

Errors in patient use of medications can lead to adverse drug events. This randomized trial demonstrated that a patient-centered label strategy improved instruction comprehension and adherence for patients with limited literacy and complex medication regimens.

Medication discrepancies between hospital and outpatient regimens can contribute to adverse events following hospital discharge. Pharmacist involvement in medication reconciliation is known to improve medication accuracy and reduce adverse drug events. This modeling study examined how implementing pharmacist-led medication reconciliation at hospital discharge affects a hospital payer's costs. Investigators calculated that an intervention that reduced medication discrepancies by 10% would be cost neutral. If pharmacist-led medication reconciliation improves accuracy as much as prior studies suggest, then implementing this process at hospital discharge should save costs. A past WebM&M commentary described a medication discrepancy that led to an adverse drug event.

Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.

This intervention study provided pharmacist support to perform medication reconciliation and care coordination for patients discharged from the hospital. Compared to similar-risk patients who did not receive the intervention, those who had medication reconciliation by pharmacists were less likely to be readmitted to the hospital. These results add to the existing literature supporting the utility of pharmacist-led care transition interventions.

Medication errors are likely the most common patient safety threat in ambulatory care, and this survey of primary care patients revealed many issues that are putting patients at risk for adverse drug events. Patients assumed that their primary care doctor was aware of all their medications, including those prescribed by other physicians, despite evidence documenting poor information sharing between community physicians. Although prior studies show that pharmacist counseling may reduce medication error rates in outpatients, only a minority of patients receiving new prescriptions reported receiving counseling (from a physician or pharmacist) regarding potential adverse effects. The discordance between patient assumptions and physician knowledge about medication regimens points to a need for greater patient engagement in medication reconciliation efforts.

Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading cause of acute liver failure in the United States, with the majority of cases being unintentional. Prior studies have shown that patients with limited health literacy frequently misunderstand dosing instructions for prescription medications, and this study examined the frequency with which adult patients misunderstood dosing instructions for acetaminophen. Patients were provided with actual bottles of medications and asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under these simulated conditions, nearly half the patients would have overdosed either by exceeding the recommended daily dose of acetaminophen or by combining two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by incorrect dosing of acetaminophen.

Limited health literacy has been linked to poor comprehension of written instructions. This study found that spoken instructions were also frequently misunderstood by patients with poor health literacy.

This study found that patients, particularly those with limited health literacy, would benefit from clearer understanding, organization, and simplification of their medication regimens.

… 2009, the US Food and Drug Administration ( FDA ) released a voluntary set of recommendations around the safety of … choose standard measurement units and abbreviations . A related editorial and news piece [see links below] discuss … for action to promote patient safety. A past AHRQ WebM&M commentary discussed a pediatric dosing error involving OTC …

Medication reconciliation discrepancies—differences between the medical record and patient self-report of their antihypertensive medications—occurred in 75% of patients in this study. These discrepancies were associated with a higher likelihood of uncontrolled hypertension. Prior research has addressed the difficult question of medication reconciliation in ambulatory care.

… Journal of general internal medicine … J Gen Intern Med … In this analysis of nearly 200,000 …

Efforts to develop health literacy interventions are one strategy to improve medication safety. In pediatric populations, the need for parents to understand liquid medication dosing poses additional risks. This study evaluated the role of dosing instrument type (e.g., cups, droppers, syringes) on parents' medication administration errors. Investigators found that dosing accuracy was lowest when using cups, and that cups were also associated with the largest deviations in dosing errors administered. Limited health literacy was also associated with parents' dosing errors. A previous WebM&M commentary discusses safety problems caused by low health literacy.  Accompanying this article [see link below] is an Advice for Patients educational page that highlights pearls for medication safety in children.

Patients' inability to correctly interpret prescription drug instructions may result in devastating errors, such as one discussed in this AHRQ WebM&M commentary. Research on minimizing these errors has focused on mitigating the relationship between low health literacy and misunderstanding drug labels that has been demonstrated in prior research. This study found that merely simplifying the text of drug warnings improved comprehension, and addition of pictorial icons to the warnings further improved comprehension among adults with low or marginal health literacy. Prior research has also successfully used visual aids to improve medication adherence in chronic disease management. The role of health literacy in patient safety is discussed in an AHRQ WebM&M perspective and interview.