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Helping to remove the barriers to patient education

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 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 errors, as well as web-based resources (Alerts for onsumers, which can be used with citation) and a consumer newsletter, Safe Medicine (

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, visit

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