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Cases & Commentaries
- Spotlight Case
- Web M&M
Alan Forster, MD, MSc; December 2004
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
Journal Article > Study
Bailey SC, Pandit AU, Yin S, et al. Fam Med. 2009;41:715-721.
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. The Joint Commission has published recommendations for improving patient–provider communication to address safety problems caused by low health literacy, an example of which is discussed in an AHRQ WebM&M commentary.