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

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.

… drug events . This randomized trial demonstrated that a patient-centered label strategy improved instruction …

… … Pediatrics … Misinterpretation of medication labels is a well-recognized source of medication error in the … when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error. …

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.

… medicine … J Gen Intern Med … Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading … asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under … two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by …

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 …

This AHRQ-funded study found that physicians usually chose appropriate reasons for excluding patients from inclusion in quality measurement programs.

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.

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.

This survey revealed that many adults do not understand instructions for common liquid prescription medications, potentially increasing the risk of serious medication errors. Prior research in this field has demonstrated that low health literacy is an important predictor of misunderstanding prescription instructions. Concerningly, in this study nearly 1 in 5 patients who had adequate health literacy could not correctly interpret the instructions, and patients with marginal or low health literacy were at even greater risk. A previous WebM&M commentary discusses safety problems caused by low health literacy. 

This study discovered variability in pharmacists' interpretation of physician prescriptions, raising concerns about the consistency of information provided to patients about safe medication use.