Prescription drug labeling medication errors: A big deal for pharmacists

G. Jeetu, T. Girish

Research output: Contribution to journalArticle

19 Citations (Scopus)

Abstract

Today, in the health care profession, all types of medication errors including missed dose, wrong dosage forms, wrong time interval, wrong route, etc., are a big deal for better patient care. Today, problems related to medications are common in the healthcare profession, and are responsible for significant morbidity, mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in reading and understanding medication labels. According to the Institute of Medicine report, "Preventing Medication Errors", cited poor labeling as a central cause for medication errors in the USA. Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although an additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.
Original languageEnglish
Pages (from-to)107-111
Number of pages5
JournalJournal of Young Pharmacists
Volume2
Issue number1
DOIs
Publication statusPublished - 2010

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Drug Labeling
Medication Errors
Prescription Drugs
Pharmacists
Delivery of Health Care
Health Occupations
National Academies of Science, Engineering, and Medicine (U.S.) Health and Medicine Division
Dosage Forms
Medicare
Reading
Patient Care
Communication
Morbidity
Costs and Cost Analysis
Mortality
Health
Therapeutics

Cite this

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title = "Prescription drug labeling medication errors: A big deal for pharmacists",
abstract = "Today, in the health care profession, all types of medication errors including missed dose, wrong dosage forms, wrong time interval, wrong route, etc., are a big deal for better patient care. Today, problems related to medications are common in the healthcare profession, and are responsible for significant morbidity, mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in reading and understanding medication labels. According to the Institute of Medicine report, {"}Preventing Medication Errors{"}, cited poor labeling as a central cause for medication errors in the USA. Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although an additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.",
author = "G. Jeetu and T. Girish",
note = "Cited By :13 Export Date: 10 November 2017 Correspondence Address: Jeetu, G.; Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India; email: jeetu.gangil@gmail.com References: Berman, A., Reducing medication errors through naming, labeling, and packaging (2004) J Med Syst, 28, pp. 9-29; Aspden, P., Wolcott, J., Bootman, L., Cronenwett, L., (2006) Preventing Medication Errors, , editors Washington DC: Institute of Medicine of the National Academies; Gurwitz, J., Field, T., Harrold, L., Incidence and preventability of adverse drug events among older persons in the ambulatory setting (2003) JAMA, 289, pp. 1107-1116; Preventing Medication Errors: The Quality Chasm Series. Institute of Medicine Report 2006, , http://www.iom.edu/en/Reports/2006/Preventing-Medication-Errors-Quality- Chasm-Series.aspx, Website information iom.edu [homepage on the Internet] Available from [updated on 2006 Jul 20]. [cited on 2009 Sep 21]; Gandhi, T., Weingart, S., Borus, J., Adverse drug events in ambulatory care (2003) N Engl J Med, 348, pp. 1556-1564; Gurwitz, J., Field, T., Harrold, L., Incidence and preventability of adverse drug events among older persons in the ambulatory setting (2003) JAMA, 289, pp. 1107-1116; Poon, E., Cina, J., Churchill, W., Patel, N., Featherstone, E., Rothschild, J., Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy (2006) Ann Intern Med, 145, pp. 426-434; Shrank, W., Avorn, J., Rolon, C., Shekelle, P., Effect of content and format of prescription drug labels on readability, understanding and medication use: A systematic review (2007) Ann Pharmacotherapy, 41, pp. 783-801; Hernandez, L.M., (2008) Standardizing Medication Labels: Confusing Patients Less: Workshop Summary, , Washington DC: Institute of Medicine; Website information jointcommission.org the Joint Commission for Accreditation of Healthcare Organizations The Offcial {"}do Not Use{"} List, , www.jointcommission.org/PatientSafety/DoNotUseList, Available from [cited on 2009 Sep 22]; Recommendations to Enhance Prescription Writing, , www.nccmerp.org/council/council1996-09-04.html, Website information nccmerp.org Available from [cited on 2009 Sep 23]; Morrell, R.W., Park, D.C., Poon LW Effects of labeling techniques on memory and comprehension of prescription information in young and old adults (1990) J Gerontol, 45, pp. 166-172; Morrell, R.W., Park, D.C., Poon, L.W., Quality of instruction on prescription drug labels: Effects on memory and comprehension in young and old adults (1989) J Gerontol, 29, pp. 345-353; Cline, C.M., Bjorck, A.K., Israelsson, B.Y., Willwnheimer, R.B., Erhardt, L.R., Non-compliance and knowledge of prescribed medication in elderly patients with heart failure (1999) Eur J Heart Fail, 1, pp. 145-149; Moisan, J., Gaudet, M., Gregoire, J.P., Bouchard, R., Non-compliance with drug treatment and reading diffculties with regard to prescription labeling among seniors (2002) J Gerontol, 48, pp. 44-51; Phillips, D.P., Christenfeld, N., Glynn, L.M., Increase in US medication-error deaths between 1983 and 1993 (1998) Lancet, 351, pp. 643-644; Medical Expenditure Panel Survey. 2003. Agency for Healthcare Research and Quality, US Dept of Health and Human Services, , http://www.meps.ahrq.gov, Website information meps.ahrq.gov Available from [cited on 2009 Sep 24]; William, H., The variability and quality of medication container labels (2007) Arch Intern Med, 167, pp. 1760-1765; Tarn, D.M., Heritage, J., Paterniti, D.A., Hays, R.D., Kravitz, R.L., Wenger, N.S., Physician communication when prescribing new medications (2006) Arch Intern Med, 166, pp. 1855-1862; Sleath, B., Roter, D., Chewning, B., Asking questions about medication: Analysis of physician-patient interactions and physician perceptions (1999) Med Care, 37, pp. 1169-1173; Schillinger, D., Piette, J., Grumbach, K., Wang, F., (2003) Closing the loop: Physician communication with diabetic patients who have low health literacy Arch Intern Med, 163, pp. 83-90; Metlay, J.P., Cohen, A., Polsky, D., Kimmel, S.E., Koppel, R., Hennessy, S., Medication safety in older adults: Home-based practice patterns (2005) J Am Geriatr Soc, 53, pp. 976-982; Stevenson, F.A., Cox, K., Britten, N., A systematic review of the research on communication between patients and health care professionals about medicines: The consequences for concordance (2004) Health Expect, 7, pp. 235-245; Wallace, L.S., Rogers, E.S., Turner, L.W., Keenum, A.J., Weiss, B.D., Suitability of written supplemental materials available on the Internet for nonprescription medications (2006) Am J Health Syst Pharm, 63, pp. 71-78; Wolf, M.S., Davis, T.C., Shrank, W., Neuberger, M., Parker, R.M., A critical review FDA approved Medication Guides (2006) Pat Educ Counsel, 62, pp. 316-322; Davis, T.C., Fredrickson, D.D., Potter, L., Brouillette, R., Bocchini, A.C., Williams, M.V., Patient understanding and use of oral contraceptive pills in a southern public health family planning clinic (2006) South Med J, 99, pp. 713-718; Insel, K., Morrow, D., Brewer, B., Figueredo, A., Executive function, working memory, and medication adherence among older adults (2006) J Gerontol B Psychol Sci Soc Sci, 61, pp. 102-107; Wolf, M.S., Davis, T.C., Bass, P.F., Tilson, H., Parker, R.M., (2006) Misunderstanding Prescription Drug Warning Labels among Patients with Low Literacy Am J Health System Pharm, 63, pp. 1048-1055; Website Information Talkaboutrx.org. National Council on Patient Information and Education (NCPIE), , http://www.talkaboutrx.org, Available from: [cited on 2009 Sep 29]; Davis, T.C., Wolf, M.S., Bass, P.F., Tilson, H., Neuberger, M., Parker, R.M., Literacy and misunderstanding of prescription drug labels (2006) Ann Intern Med, 145, pp. 887-894; Davis, T.C., Wolf, M.S., Bass, P.F., Middlebrooks, M., Kennan, E., Baker, D.W., Low literacy impairs comprehension of prescription drug warning labels (2006) J Gen Intern Med, 21, pp. 847-851; (2007) A Health Literacy and Medication Safety Initiative, pp. 13-14. , A White Paper Commissioned by the American College of Physicians: Foundation: Presented to the Institute of Medicine Roundtable on Health Literacy Improving Prescription Drug Container Labeling in the United States Oct 12; Shrank, W.H., Agnew, J., Choudry, N., Wolf, M.S., Kesselheim, A., Avorn, J.L., The variability and poor quality of medication container labels: A prescription for confusion (2007) Arch Intern Med, 166, pp. 1760-1765; Wolf, M.S., Shrank, W.H., Choudry, N.K., Agnew, J., Parker, R.M., Shekelle, P., Variability in pharmacy interpretations of physician prescriptions (2009) J Gen Intern Med, 47, pp. 370-373; Hernandez, L.M., (2008) Standardizing Medication Labels: Confusing Patients Less: Workshop Summary, , http://books.nap.edu/openbook.php?record_id=12077, Website information book.naps.edu Institute of Medicine Washington DC Available from: [cited on 2009 Oct 4]; Stephen, D., Comparison of Handwritten and Electronically Generated Prescription Drug Instructions, , http://www.theannals.com/cgi/reprint/43/1/151, Website information theannals.com Available from: [updated on 2009 Jan 6]; [cited on 2009 Sep 21]; Shrank, W.H., Avorn, J., Rol{\'o}n, C., Shekelle, P., The effect of the content and format of prescription drug labels on readability, understanding and medication use: A systematic review (2007) Ann Pharmacother, 41, pp. 783-801",
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}

Prescription drug labeling medication errors: A big deal for pharmacists. / Jeetu, G.; Girish, T.

In: Journal of Young Pharmacists, Vol. 2, No. 1, 2010, p. 107-111.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Prescription drug labeling medication errors: A big deal for pharmacists

AU - Jeetu, G.

AU - Girish, T.

N1 - Cited By :13 Export Date: 10 November 2017 Correspondence Address: Jeetu, G.; Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India; email: jeetu.gangil@gmail.com References: Berman, A., Reducing medication errors through naming, labeling, and packaging (2004) J Med Syst, 28, pp. 9-29; Aspden, P., Wolcott, J., Bootman, L., Cronenwett, L., (2006) Preventing Medication Errors, , editors Washington DC: Institute of Medicine of the National Academies; Gurwitz, J., Field, T., Harrold, L., Incidence and preventability of adverse drug events among older persons in the ambulatory setting (2003) JAMA, 289, pp. 1107-1116; Preventing Medication Errors: The Quality Chasm Series. Institute of Medicine Report 2006, , http://www.iom.edu/en/Reports/2006/Preventing-Medication-Errors-Quality- Chasm-Series.aspx, Website information iom.edu [homepage on the Internet] Available from [updated on 2006 Jul 20]. [cited on 2009 Sep 21]; Gandhi, T., Weingart, S., Borus, J., Adverse drug events in ambulatory care (2003) N Engl J Med, 348, pp. 1556-1564; Gurwitz, J., Field, T., Harrold, L., Incidence and preventability of adverse drug events among older persons in the ambulatory setting (2003) JAMA, 289, pp. 1107-1116; Poon, E., Cina, J., Churchill, W., Patel, N., Featherstone, E., Rothschild, J., Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy (2006) Ann Intern Med, 145, pp. 426-434; Shrank, W., Avorn, J., Rolon, C., Shekelle, P., Effect of content and format of prescription drug labels on readability, understanding and medication use: A systematic review (2007) Ann Pharmacotherapy, 41, pp. 783-801; Hernandez, L.M., (2008) Standardizing Medication Labels: Confusing Patients Less: Workshop Summary, , Washington DC: Institute of Medicine; Website information jointcommission.org the Joint Commission for Accreditation of Healthcare Organizations The Offcial "do Not Use" List, , www.jointcommission.org/PatientSafety/DoNotUseList, Available from [cited on 2009 Sep 22]; Recommendations to Enhance Prescription Writing, , www.nccmerp.org/council/council1996-09-04.html, Website information nccmerp.org Available from [cited on 2009 Sep 23]; Morrell, R.W., Park, D.C., Poon LW Effects of labeling techniques on memory and comprehension of prescription information in young and old adults (1990) J Gerontol, 45, pp. 166-172; Morrell, R.W., Park, D.C., Poon, L.W., Quality of instruction on prescription drug labels: Effects on memory and comprehension in young and old adults (1989) J Gerontol, 29, pp. 345-353; Cline, C.M., Bjorck, A.K., Israelsson, B.Y., Willwnheimer, R.B., Erhardt, L.R., Non-compliance and knowledge of prescribed medication in elderly patients with heart failure (1999) Eur J Heart Fail, 1, pp. 145-149; Moisan, J., Gaudet, M., Gregoire, J.P., Bouchard, R., Non-compliance with drug treatment and reading diffculties with regard to prescription labeling among seniors (2002) J Gerontol, 48, pp. 44-51; Phillips, D.P., Christenfeld, N., Glynn, L.M., Increase in US medication-error deaths between 1983 and 1993 (1998) Lancet, 351, pp. 643-644; Medical Expenditure Panel Survey. 2003. Agency for Healthcare Research and Quality, US Dept of Health and Human Services, , http://www.meps.ahrq.gov, Website information meps.ahrq.gov Available from [cited on 2009 Sep 24]; William, H., The variability and quality of medication container labels (2007) Arch Intern Med, 167, pp. 1760-1765; Tarn, D.M., Heritage, J., Paterniti, D.A., Hays, R.D., Kravitz, R.L., Wenger, N.S., Physician communication when prescribing new medications (2006) Arch Intern Med, 166, pp. 1855-1862; Sleath, B., Roter, D., Chewning, B., Asking questions about medication: Analysis of physician-patient interactions and physician perceptions (1999) Med Care, 37, pp. 1169-1173; Schillinger, D., Piette, J., Grumbach, K., Wang, F., (2003) Closing the loop: Physician communication with diabetic patients who have low health literacy Arch Intern Med, 163, pp. 83-90; Metlay, J.P., Cohen, A., Polsky, D., Kimmel, S.E., Koppel, R., Hennessy, S., Medication safety in older adults: Home-based practice patterns (2005) J Am Geriatr Soc, 53, pp. 976-982; Stevenson, F.A., Cox, K., Britten, N., A systematic review of the research on communication between patients and health care professionals about medicines: The consequences for concordance (2004) Health Expect, 7, pp. 235-245; Wallace, L.S., Rogers, E.S., Turner, L.W., Keenum, A.J., Weiss, B.D., Suitability of written supplemental materials available on the Internet for nonprescription medications (2006) Am J Health Syst Pharm, 63, pp. 71-78; Wolf, M.S., Davis, T.C., Shrank, W., Neuberger, M., Parker, R.M., A critical review FDA approved Medication Guides (2006) Pat Educ Counsel, 62, pp. 316-322; Davis, T.C., Fredrickson, D.D., Potter, L., Brouillette, R., Bocchini, A.C., Williams, M.V., Patient understanding and use of oral contraceptive pills in a southern public health family planning clinic (2006) South Med J, 99, pp. 713-718; Insel, K., Morrow, D., Brewer, B., Figueredo, A., Executive function, working memory, and medication adherence among older adults (2006) J Gerontol B Psychol Sci Soc Sci, 61, pp. 102-107; Wolf, M.S., Davis, T.C., Bass, P.F., Tilson, H., Parker, R.M., (2006) Misunderstanding Prescription Drug Warning Labels among Patients with Low Literacy Am J Health System Pharm, 63, pp. 1048-1055; Website Information Talkaboutrx.org. National Council on Patient Information and Education (NCPIE), , http://www.talkaboutrx.org, Available from: [cited on 2009 Sep 29]; Davis, T.C., Wolf, M.S., Bass, P.F., Tilson, H., Neuberger, M., Parker, R.M., Literacy and misunderstanding of prescription drug labels (2006) Ann Intern Med, 145, pp. 887-894; Davis, T.C., Wolf, M.S., Bass, P.F., Middlebrooks, M., Kennan, E., Baker, D.W., Low literacy impairs comprehension of prescription drug warning labels (2006) J Gen Intern Med, 21, pp. 847-851; (2007) A Health Literacy and Medication Safety Initiative, pp. 13-14. , A White Paper Commissioned by the American College of Physicians: Foundation: Presented to the Institute of Medicine Roundtable on Health Literacy Improving Prescription Drug Container Labeling in the United States Oct 12; Shrank, W.H., Agnew, J., Choudry, N., Wolf, M.S., Kesselheim, A., Avorn, J.L., The variability and poor quality of medication container labels: A prescription for confusion (2007) Arch Intern Med, 166, pp. 1760-1765; Wolf, M.S., Shrank, W.H., Choudry, N.K., Agnew, J., Parker, R.M., Shekelle, P., Variability in pharmacy interpretations of physician prescriptions (2009) J Gen Intern Med, 47, pp. 370-373; Hernandez, L.M., (2008) Standardizing Medication Labels: Confusing Patients Less: Workshop Summary, , http://books.nap.edu/openbook.php?record_id=12077, Website information book.naps.edu Institute of Medicine Washington DC Available from: [cited on 2009 Oct 4]; Stephen, D., Comparison of Handwritten and Electronically Generated Prescription Drug Instructions, , http://www.theannals.com/cgi/reprint/43/1/151, Website information theannals.com Available from: [updated on 2009 Jan 6]; [cited on 2009 Sep 21]; Shrank, W.H., Avorn, J., Rolón, C., Shekelle, P., The effect of the content and format of prescription drug labels on readability, understanding and medication use: A systematic review (2007) Ann Pharmacother, 41, pp. 783-801

PY - 2010

Y1 - 2010

N2 - Today, in the health care profession, all types of medication errors including missed dose, wrong dosage forms, wrong time interval, wrong route, etc., are a big deal for better patient care. Today, problems related to medications are common in the healthcare profession, and are responsible for significant morbidity, mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in reading and understanding medication labels. According to the Institute of Medicine report, "Preventing Medication Errors", cited poor labeling as a central cause for medication errors in the USA. Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although an additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.

AB - Today, in the health care profession, all types of medication errors including missed dose, wrong dosage forms, wrong time interval, wrong route, etc., are a big deal for better patient care. Today, problems related to medications are common in the healthcare profession, and are responsible for significant morbidity, mortality, and cost. Several recent studies have demonstrated that patients frequently have difficulty in reading and understanding medication labels. According to the Institute of Medicine report, "Preventing Medication Errors", cited poor labeling as a central cause for medication errors in the USA. Evidence suggests that specific content and format of prescription drug labels facilitate communication with and comprehension by patients. Efforts to improve the labels should be guided by such evidence, although an additional study assessing the influence of label design on medication-taking behavior and health outcomes is needed. Several policy options exist to require minimal standards to optimize medical therapy, particularly in light of the new Medicare prescription drug benefit.

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DO - 10.4103/0975-1483.62218

M3 - Article

VL - 2

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EP - 111

JO - Journal of Young Pharmacists

JF - Journal of Young Pharmacists

SN - 0975-1483

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