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Prescription Instructions Confuse Even Educated Patients

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   March 02, 2011

Even for highly educated patients, following instructions to take multiple  medications a day is a daunting task that can lead to missed or incorrectly administered doses, according to an experiment published Monday in the Archives of Internal Medicine.

The 464 volunteers were asked to organize taking seven hypothetical prescription medications  – 21 fake pills in all – by placing them in a box with 24 compartments representing hours of the day.

While all the pills could be consolidated into just four time slots, 8 a.m., noon, 6 p.m. and bedtime, most of patients largely couldn't see that because of the confusing way the prescription labels were worded. Instead of four slots, many of the patients organized the 21 fake pills in as many as 14 time slots, from 5 a.m. to 11 p.m.

Only 15% of the participants got it right.

For example, even though instructions for taking two of the drugs were identical – "take one tablet by mouth three times daily" – nearly one third of the volunteers put those drugs in separate time slots.

The failure to follow the instructions and correctly group the times when the pills should be taken was also associated with scoring low on a literacy assessment test known as the "Newest Vital Sign," a six-item quiz that measures reading skills based on the participant's comprehension of a food nutrition label.

The study, by Michael Wolf of Northwestern's Health Literacy and Learning Program at Feinberg School of Medicine and colleagues, supports a move to a new UMS or Universal Medication Scheduling system to standardize the way physicians and pharmacists recommend dosages.

For example, instead of writing "every 12 hours," and "twice a day," instructions would read, 8 a.m. and 6 p.m. One prescription might read, "take 2 tablets by mouth every 12 hours," while a second prescription might read, "take 2 tablets by mouth in morning and evening." That's the same instruction, but may be interpreted to mean the drugs must be taken at different times.

"Our findings demonstrate that most patients may self-administer multidrug regimens more times a day than necessary and that those with limited literacy are at greater risk," the authors wrote.  "This increased complexity, at the every least, translates to taking medication too often each day, leading to substantial interference with patients' lives. As a result, doses may be frequently missed or incorrectly administered."

The researchers added that their report, the first of its kind, "offers "compelling, preliminary evidence of the need to help all patients more clearly understand, organize and simplify their medication regimens."

The researchers gave two reasons why the problem could be a lot worse than their experiment demonstrated. First, nearly two thirds of their participants had a household income of more than $50,000 a year and nearly two-thirds of the volunteers also had a college degree, and as such were considered highly educated.

Second, while these volunteers, whose average age was 63, were vexed trying to organize seven medications, patients over age 65 on average grapple with 20 prescriptions per year. Other over-the-counter medications could confuse the schedule further.  "Our findings should be viewed as the best case scenario, as more socioeconomically disadvantaged patients are more likely to have limited health literacy and face even greater difficulty in organizing and dosing complex medication regimens," they wrote.

According to an Institute of Medicine report from 2008, "Standardizing Medication Labels; Confusing Patients Less," there is a great need for setting uniform prescribing and dispensing practices by both [pharmacists and physicians. The IOM report said that because 90% of medications are taken four or fewer times a day, such a medication schedule that calls for morning, noon, evening and bedtime would go a long way to resolving the confusion.

The researchers cautioned that even more standardized simplified bottle labeling would need to be supplemented with spoken communication by the prescriber and pharmacist to make sure patients understand how their medications should be taken.

"Educational and health system strategies are needed to target provider communication skills and screening methods for identifying those at risk for complicating regimens and poor adherence," they wrote.

The participants who volunteered for this study ware between the ages of 55 and 75 and sought care at an internal medicine ambulatory care clinic or at one of three federally qualified health centers in Chicago. They were enrolled between August 2008 and December, 2009. The study was funded by the National Institute on Aging.

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