From the October 2, 2003 issue
What are the most frequent barriers that nurses encounter
when teaching patients about their medications? Over 250 nurses
answered this question in a June 2003 survey distributed with
our nursing newsletter, Nurse Advise-ERR. Their responses
tell a story of successes and challenges with this considerable
responsibility - a responsibility that nurses clearly share
with other health providers, including physicians, pharmacists,
and healthcare managers. As such, the survey also uncovered
distinct areas where various health providers can offer support
to nurses who are educating patients about their medications.
Written information about medications. While most
nurses told us they consistently provided verbal information
to patients about their medications, few offered written
information to patients (1 in 4 nurses never provided it).
Several possible reasons were disclosed. One in four nurses
told us that written materials were not available or quite
scarce, even more so for patients who did not read English.
This was reported more frequently in teaching hospitals,
perhaps because of the cultural diversity of the patient
population. When written materials were available, 1 in
4 nurses said they were often unsuitable for their patients'
health literacy or reading level; and 1 in 3 felt the materials
did not cover important information clearly.
Pharmacists and physicians should work with nurses to explore
ways to make suitable written materials more readily available
for patients. If computer terminals (and a printer) reside
in patient care units, electronic databases may provide
one solution. A few systems offer patient leaflets in different
reading levels as well as in several languages. To ensure
that these systems meet your needs, find out the average
reading level in your community and the predominant languages
spoken (such information may be available from local government).
Also, management support for widespread education is paramount
so that nurses, pharmacists, and physicians effectively
use the electronic resource to provide information to patients.
If electronic databases are not feasible in all patient
care units, pharmacy should provide paper leaflets (updated
annually) for the most commonly used medications. Be sure
to seek feedback from patients (e.g., focus groups, targeted
satisfaction survey questions) and providers (e.g., primary
care physicians) to ensure that the written materials effectively
communicate the most important information.
Written information on error prevention. Half of
the nurses who responded to the survey told us they have
no written information to provide to patients about preventing
medication errors, making this one of the frequently reported
barriers. Yet, some information is currently available on
this topic. For example, the Agency for Healthcare Research
and Quality (AHRQ) recently made several publications available
at www.ahrq.gov: Your
Medicine: Play it Safe (produced with the National Council
on Patient Information and Education) and 20 Tips to Help
Prevent Medical Errors in Children (produced with the American
Academy of Pediatrics). ISMP also offers an informative
pamphlet on the patient's role in preventing medication
as well as web-based resources (Alerts for onsumers, which
can be used with citation) and a consumer newsletter, Safe
Pharmacists could also help develop error prevention materials
for specific targeted areas. To start, ask physicians (especially
in the ED), other prescribers, and nurses to suggest medications,
therapeutic categories of drugs, or drug administration
systems that they believe are error prone (e.g., metered
dose inhalers, low molecular weight heparin, acetaminophen
dosing for children). Another way to uncover problems is
to review the reason for patient readmissions to determine
if confusion about a medication played a role (e.g., warfarin,
digoxin). Be sure the materials focus on the ways that errors
could happen (e.g., delays in restarting warfarin after
a "hold" order; taking both a generic and brand
of the same medication), and how patients can protect themselves.
Pharmacists and physicians should also determine if a new
formulary drug requires special patient education, and seek
out or develop any necessary patient materials before the
product is added to the formulary.
Time constraints. Lack of time for patient education
was a frequent barrier for almost half of all nurses, more
so in inpatient settings than outpatient settings. Similar
time constraints for pharmacists suggest that targeted consultations
to a pharmacist for a few error-prone conditions (e.g.,
patients discharged on numerous prescription medications)
may prove to be the most effective educational support.
Physicians can also help by identifying patients who require
in-depth education, ordering pharmacy consultations, and
by listing the medications that are anticipated upon discharge
in progress notes so nurses can begin educating patients
before the day of discharge. For additional survey results,