Effect of pharmaceutical pictograms on the textual comprehension of Prescription Medication Leaflets: A randomized controlled trial

INTRODUCTION

Clear patient instructions are essential in pharmaceutical care. However, literature reveals a consistent gap between the readability of medication messages and population skills. This study aimed to assess the comprehension of information in three Prescription Medication Leaflets, with and without supplementary US Pharmacopeia (USP) pictograms, among Spanish adolescents completing secondary education.

METHODS

We conducted a multicenter randomized controlled trial. From March to June 2022, 590 students were randomly assigned to read Prescription Medication Leaflets for ibuprofen, amoxicillin/clavulanic acid, and omeprazole, with or without USP pictograms. Comprehension was evaluated via questionnaire, alongside the European Health Literacy Survey short form, and sociodemographic data were collected. Mann-Whitney U and chi-square tests were used for analysis.

RESULTS

Participant comprehension was significantly below the European standard, which requires at least 80 % readability for Prescription Medication Leaflets, even with pictograms. Pictograms, however, significantly enhanced comprehension across all medication package inserts (p < 0.001 for all comparisons), especially among students with higher health literacy. High health literacy was a statistically significant factor in comprehension only within the experimental group (p = 0.005; p = 0.039; p = 0.004).

CONCLUSION

The discouraging results highlight the imperative for innovation in medication labeling design, employing patient-centered approaches. USP pictograms have been shown to significantly enhance the reading comprehension of medication package inserts among the Spanish population.

Alignment of Patient Information Leaflets with the Health Literacy Skills of Future End-Users: Are We on the Same Page?

Effective health communication will not be possible if the messages directed to patients do not adapt to their health literacy skills. In this sense, if the Patient Information Leaflets (PILs) are not understood properly, they will not fulfill their purpose. Secondary education aims to develop students' fundamental skills, including reading comprehension, which should align with future patients. This study assesses reading comprehension of commonly used PILs among secondary education students. An observational cross-sectional study involved 590 Spanish secondary school students from March to June 2022. They read 3 original PILs and completed a questionnaire about medication use information. The European health literacy survey questionnaire (short version) and sociodemographic data were collected. The average correct answer rate was only 51%, with just 14.58% understanding when to take ibuprofen, results that fell significantly below the minimum 80% threshold required by the European Union. Age, gender, and cultural background didn't significantly impact comprehension. In conclusion, health literacy skills acquired in secondary education are insufficient for understanding current PILs. Educational reform is necessary to improve students' ability to comprehend medication instructions and enhance PILs for effective communication. At the same time, our work highlights that current PILs need to be redesigned to reduce the cognitive burden imposed on patients.

Syntax Error: Variations in the Verbiage of Prescription Labels for Pediatric Liquid Medications

Background Pharmacists can modify prescriptions from prescribers for clarity and patient understanding, provided the confines of the original order are met, yet the verbiage used by pharmacists is not standardized. Prescription directions for children, especially children eight years old and younger, should be written with the verb "give" instead of "take" as their parents or caregivers are expected to administer them. Errors in prescribing, dispensing, and administering medication comprise a significant portion of preventable medical errors in children. To intervene and assist pharmacies, we must first identify and characterize the problem. This study aimed to determine if there is a relationship between prescribers and pharmacists using the verb "give" or "take" when prescribing and printing prescription labels for pediatric liquid medications. In addition, it aimed to determine if there is a relationship between chain pharmacies and independent pharmacies using the verb "give" or "take" when printing labels for pediatric liquid medications. Methodology The participants in this study were caregivers of children eight years old and younger who had been prescribed a new liquid medication. We recruited prescribers in North Louisiana to serve as a referral base for the study. Caregivers were referred to the study by prescribers. A rubric was created to investigate the text of prescription labels. Fisher's exact test was used to determine the relationship between verb choice and prescribers and pharmacists, as well as the relationship between verb choice and chain pharmacies and independent pharmacies. Results A total of 11 (26.83%) prescriber texts used the verb "give," while 12 (29.27%) prescriber texts used the verb "take." Overall, 18 (43.90%) prescriber texts did not use a verb at all. Of these 18 prescriber texts that did not include a verb, 14 prescription labels used the verb "give," and four used the verb "take." In total, 10 (23.81%) chain pharmacy prescription labels used the verb "give," and 10 (23.81%) chain pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between prescribers and pharmacists equaled 0.0001. A total of 19 (46.34%) independent pharmacy prescription labels used the verb "give," and two (4.88%) independent pharmacy prescription labels used the verb "take." The two-tailed p-value of Fisher's exact test comparing verb choice between chain pharmacies and independent pharmacies equaled 0.0063. Conclusions The relationship between prescriber texts and pharmacist prescription labels shows a relationship between their verb choice (p = 0.0001). The relationship between chain pharmacy and independent pharmacy prescription labels shows a relationship between their verb choice (p = 0.0063). This study has illuminated how medication orders begin before they are modified, if necessary, for the patient's clarity and understanding. This study can be used to instruct prescribers on writing more accurate prescription instructions to prevent medical errors, and it can help pharmacists recognize potential dangers and prevent them through editing.

Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review

INTRODUCTION

Patient misunderstanding of instructions on medication labels is a common cause of medication errors and can result in ineffective treatment. One way to better improve patient comprehension of medication labels is by optimizing the content and display of the information.

OBJECTIVES

To review comparative studies that have evaluated the design of a medication label to improve patient knowledge or safety.

METHODS

Studies were selected from systematic computerized literature searches performed in PubMed, Embase (Elsevier), Cochrane Central (EBSCO), Cumulative Index to Nursing and Allied Health Literature-CINAHL (EBSCO), and Web of Science (Thomson Reuters). Eligible studies included comparative studies that evaluated the design of a medication label to improve patient knowledge or safety.

RESULTS

Of the 246 articles identified in the primary literature search, 14 studies were selected for data abstraction. Thirteen of these studies significantly impacted the patient understanding of medication labels. Three studies included a measure of patient safety in terms of medication adherence and dosing errors. The utilization of patient-centered language, pictograms/graphics, color/white space, or font optimization was seen to have the most impact on patient comprehension.

CONCLUSION

It is essential to present medication information in an optimal manner for patients. This can be done by standardizing the content, display, and format of medication labels to improve understanding and medication usage. Evidence-based design principles can, therefore, be used to facilitate the standardization of the structure of label content for both print and electronic devices. However, more research needs to be done on validating the implications of label content display to measure its impact on patient safety.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42022347510 ( http://www.crd.york.ac.uk/prospero/ ).

Older adult patient preferences for the content and format of prescription medication labels - A best-worst scaling and discrete choice experiment study

BACKGROUND

Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints.

OBJECTIVES

We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore.

METHODS

Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes.

RESULTS

The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour.

CONCLUSIONS

Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences.

Comprehensibility of a personalized medication overview compared to usual-care prescription drug labels

Poor understanding of prescription drug label (PDL) instructions can lead to medication errors, suboptimal treatment (side) effects, and non-adherence. A personalized medication hard-copy overview listing PDL instructions and visual information may support patients in their medication use. This study aimed to investigate the comprehensibility of PDL instructions on a personalized medication overview compared to usual-care PDL instructions presented on a medication box. A hypothetical-online-experiment was set up, comparing groups of respondents exposed vs not exposed to the medication overview and who received PDL instructions for three, five, or eight medications. Participants were divided randomly in six groups. Online questionnaires were sent to a stratified sample of 900 members from the Nivel Dutch Healthcare Consumer Panel. Outcome measures included comprehension of instructions for medication use, e.g. how often, dose timing, usage advice and warnings for a medication with simple use instructions (omeprazol) and more complex use instructions (levodopa/carbidopa (L/C)). To analyze differences between experimental conditions ANOVA testing was used. 604 respondents (net response 67%) completed the questionnaires. Respondents exposed (E) to the overview gave a higher proportion of correct answers compared to non-exposed (NE) respondents for usage advice (L/C: mean 0.83, SD 0.4 E; 0.03, SD 0.2 NE, p &lt; 0.001; omeprazol: mean 0.85, SD 0.4 E; 0.10, SD 0.3 NE, p &lt; 0.001). Both groups gave the same proportion of correct answers (mean 0.80, SD 0.4, p = 1.0) for dose timing of omeprazol. More NE respondents gave correct answers for how often (mean 0.85, SD 0.4 NE; mean 0.76, SD 0.4 E, p = 0.02) and dose timing (mean 0.92, SD 0.3 NE; mean 0.86, SD 0.4 E, p = 0.04) of L/C. No differences were found regarding number of medications nor were interaction effects found between the number of medications and information type. As a medication overview contains additional information, it can be a good addition in supporting patients in their medication use compared to usual-care PDLs. Future research should focus on identifying patient groups who might benefit more from a medication overview, by testing the effect of such overview on this group.

Evaluating Providers' Prescription Opioid Instructions to Pediatric Patients

Receiving an opioid prescription during childhood increases the risk of hazardous prescription opioid (PO) use during emerging adulthood. Instruction on how to safely use POs plays an essential role in pediatric patients’ capacity to utilize as well as to discontinue POs appropriately. This study aimed to evaluate pediatric PO label instructions provided to a large sample of pediatric outpatients. Data were extracted from the electronic healthcare records system identifying pediatric patients who received a PO between 2016 and 2019 from pediatric outpatient medical clinics were affiliated with a northwestern United States medical center and children’s hospital. Pediatric patients (n = 12,613) between 0−17 years old who received a PO during outpatient care were included. Patients with chronic health conditions (e.g., cancer) or who received their PO from an inpatient medical setting were excluded. Patient demographics, medication instructions, associated diagnoses, and other prescription information (e.g., name of medication, dose, and quantity dispensed) were examined using automated text classification. Many label instructions did not include any indication/reason for use (20.8%). Virtually none of the POs (>99%) included instructions for how to reduce/wean off POs, contact information for questions about the POs, and/or instructions around how to dispose of the POs. Efforts are needed to ensure that pediatric PO instructions contain essential elements to improve comprehension of when and how to use POs for pediatric patients.

A Review of Patient-Reported Outcome Labeling of FDA-Approved New Drugs (2016-2020): Counts, Categories, and Comprehensibility

OBJECTIVES

A review of new drug approvals (NDAs) by the US Food and Drug Administration (FDA) for 2006 to 2015 showed that approximately 20% of new drugs had labeling based on patient-reported outcomes (PROs). The purpose of this study was to review labeling text based on PRO endpoints for NDAs from 2016 to 2020, with a special focus on the comprehensibility of such statements when included.

METHODS

We reviewed drug approval reports on the Drugs@FDA web page of the FDA website to determine the number of NDAs from 2016 to 2020. For all identified NDAs, drug approval package and product labels were reviewed. NDAs from 2016 to 2020 were grouped by disease category as per International Classification of Diseases 10th Revision. Data were summarized for diseases that traditionally rely on PROs for evaluating treatment benefit (PRO dependent) and for diseases that traditionally do not rely on PROs (non-PRO dependent). Results were compared with NDAs from 2006 to 2010.

RESULTS

NDAs amounting to 228 were identified from 2016 to 2020, 26.3% of which had labeling statements based on PRO endpoints. From 2006 to 2015 and from 2016 to 2020, PRO labeling statements were included in 46.5% (46 of 99) and 50.0% (47 of 94), respectively, of NDAs for PRO-dependent new molecular entities and in 6.0% (12 of 199) and 9.7% (13 of 199), respectively, of NDAs for non-PRO-dependent new molecular entities. Comprehensibility of labeling statements based on PRO endpoints was judged to be complex in 56.7% of product labels.

CONCLUSIONS

The increase in labeling text based on PRO endpoints in product labels is encouraging. However, there is room for improvement on the comprehensibility of labeling statements based on PRO endpoints.

Older adult and family caregiver experiences with prescription medication labels and their suggestions for label improvement

Background

Prescription medication labels (PMLs) are an important source of written medication information for patients. However, real-world PMLs do not entirely conform with available labelling best practices and guidelines. Given this disconnect, older adults remain particularly at risk of misinterpreting their PMLs. Past studies have commonly assessed hypothetical PMLs, warranting studies that explore the lived experiences of older adults with real-world PMLs. Furthermore, the perspective of family caregivers of older adults is yet to be studied.

Objective(s)

This qualitative study documented the challenges faced by older adults and their family caregivers in using real-world PMLs, their strategies to cope with these challenges, and their suggestions to improve existing PMLs.

Methods

We conducted two focus group discussions (n = 17) and 30 in-depth interviews with older adults (n = 20; including those who can read in English and those with limited English proficiency) and caregivers (n = 10) in Singapore. The data were systematically assigned to codes that were continuously refined to accommodate emergent themes.

Results

Challenges, coping strategies and suggested improvements were related to the comprehensibility, availability, readability and consistency of medication information on PMLs.

Conclusions

Real-world PMLs continue to pose challenges for older adults and their caregivers, necessitating them to seek unique and personal coping strategies. The identified PML improvements, desired by older adults and their caregivers, urge healthcare systems to implement improved PMLs. Future research should explore system-level logistical, financial, and administrative barriers (or opportunities) that hinder (or facilitate) this implementation.

•

Older adults and caregivers still face challenges with English medicine labels.

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Small font and lack of desired information were also enduring challenges.

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Inconsistency in label format and content confused older adults and caregivers.

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Caregivers and pharmacy staff adopted unique strategies to help older adults.

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Challenges and ad-hoc strategies necessitate real-world, systemic change to labels.

Investigating the impact of patient-centred labels on comprehension of medication dosing: a randomised controlled trial

OBJECTIVE

This study aims to implement a version of patient-centred labels (PCL) consistent with current labelling practice in Australia; assess the effectiveness of PCL in relation to the proportion of participants that correctly comprehend dosing instructions, and explore the proportion of correct comprehension of PCL in participants with both low and high health literacy.

DESIGN

Randomised controlled trial.

SETTING

A large tertiary care hospital in Brisbane, Queensland, Australia.

PARTICIPANTS

121 participants with a majority born in Australia (65.3%), New Zealand (14.0%), the UK (6.6%) and Ireland (2.5%).

INTERVENTION

Participants were randomly assigned to either a panel of three PCL (n=61) or three standard labels (n=60) and asked to comprehend their assigned panel of labels.

OUTCOME MEASURES

Difference in the proportion of participants that correctly comprehend dosing instructions provided on PCL compared with standard labels. The two-proportion test was used to measure the impact of PCL on the proportion of participants correctly comprehending dosing instructions.

RESULTS

A greater proportion of participants were able to accurately comprehend PCL compared with standard labels. The proportion of participants who were able to correctly comprehend dose instructions provided on all three labels was significantly higher in the group that received PCL; 23.3% standard vs 83.6% PCL, p<0.001. The effect was observed in both low and high health literacy participants. The proportion of participants with accurate label comprehension was higher in participants with low Newest Vital Signs scores (8.3% standard vs 85.7% PCL, p<0.001) and low Rapid Estimate of Adult Literacy in Medicine scores (10.5% standard vs 96.0% PCL, p<0.001) who received PCL.

CONCLUSION

This study supports the use of PCL in Australian pharmacy practice. PCL provide simple, clear and explicit dosing instructions to patients. Implementing PCL may reduce the risk of misinterpreting dosing instructions by patients and improve quality use of medicines.

TRIAL REGISTRATION NUMBER

ACTRN12621000083897; Results.

Developing and user testing new pharmacy label formats-A study to inform labelling standards

Background

Dispensed prescription medicine labels (prescription labels) are important information sources supporting safe and appropriate medicines use.

Objective

To develop and user test patient‐centred prescription label formats.

Methods

Five stages: developing 12 labels for four fictitious medicines of varying dosage forms; diagnostic user testing of labels (Round 1) with 40 consumers (each testing three labels); iterative label revision, and development of Round 2 labels (n = 7); user testing of labels (Round 2) with 20 consumers (each testing four labels); labelling recommendations. Evaluated labels stated the active ingredient and brand name, using various design features (eg upper case and bold). Dosing was expressed differently across labels: frequency of doses/day, approximate times of day (eg morning), explicit times (eg 7 to 9 AM), and/or explicit dosing interval. Participants’ ability to find and understand medicines information and plan a dosing schedule were assessed.

Results

Participants demonstrated satisfactory ability to find and understand the dosage for all label formats. Excluding active ingredient and dosing schedule, 14/19 labels (8/12 in Round 1; 6/7 in Round 2) met industry standard on performance. Participants’ ability to correctly identify the active ingredient varied, with clear medicine name sign‐posting enabling all participants evaluating these labels to find and understand the active ingredient. When planning a dosing schedule, doses were correctly spaced if the label stated a dosing interval, or frequency of doses/day. Two‐thirds planned appropriate dosing schedules using a dosing table.

Conclusions

Effective prescription label formatting and sign‐posting of active ingredient improved communication of information on labels, potentially supporting safe medicines use.

Patient and Public Involvement

Consumers actively contributed to the development of dispensed prescription medicine labels. Feedback from consumers following the first round was incorporated in revisions of the labels for the next round. Patient and public involvement in this study was critical to the development of readable and understandable dispensed prescription medicine labels.

Development of salient medication reminders to facilitate information transfer during transition from inpatient to primary care: the Delphi process

OBJECTIVE

Transitional care is important to successful hospital discharge. Providing patients with a clear and concise summary of medication-related information can help improve outcomes, in particular, among older adults. The present study aimed to propose a framework for the development of salient medication reminders (SMR), which include drug-related risks and precautions, using the Delphi process.

DESIGN

Identification of potential SMR statements for 80% of medication types used by older adult patients discharged from geriatric medicine departments, followed by a Delphi survey and expert panel discussion.

SETTINGS

Medical and geriatric departments of public hospitals in Hong Kong.

PARTICIPANTS

A panel of 13 geriatric medical experts.

OUTCOME MEASURE

A Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) points, scoring item relevance, importance and clarity. The minimum of 70% consensus was required for each statement to be included.

RESULTS

The expert panel achieved consensus through the Delphi process on 80 statements for 44 medication entities. Subsequently, the SMR steering group endorsed the inclusion of these statements in the SMR to be disseminated among older adults at the time of discharge from geriatric medicine departments.

CONCLUSIONS

The Delphi process contributed to the development of SMR for older adult patients discharged from public hospitals in Hong Kong. Patient experience with and staff response to the SMR were assessed at four hospitals before implementation at all public hospitals.

Enhancing Patient Understanding of Medication Risks and Benefits

Objective

To evaluate the effectiveness of 2 interventions, including the DrugFactsBox format for presenting written medication information and the SMART (Strategic Memory Advanced Reasoning Training) program designed to enhance gist (i.e., “bottom‐line” meaning) reasoning ability.

Methods

We used a 2 × 2 factorial research design. A total of 286 patients with rheumatoid arthritis were randomly assigned to 1 of 4 groups, including DrugFactsBox with the SMART program, DrugFactsBox without the SMART program, other consumer medication information (CMI) with the SMART program, and other CMI without the SMART program. Data were collected via telephone interviews and online questionnaires at 4 time points, including baseline and 6‐week, 3‐month, and 6‐month time points following baseline. The primary outcome variable was informed decision‐making, which was defined as making a value‐consistent decision concerning use of disease‐modifying antirheumatic drugs based on adequate knowledge.

Results

We found no main effects for the 2 interventions, either alone or in combination. However, there was a significant interaction between assignment to the SMART/no SMART groups and informed decision‐making at baseline. Among participants in the SMART groups who did not meet the criteria for informed decision‐making at baseline, 42.5% met the criteria at the 6‐month follow‐up, compared to 23.6% of participants in the no SMART groups (mean difference 18.9 [95% confidence interval 5.6, 32.2]; P = 0.007). This difference was driven by increased knowledge in the SMART groups. Among participants who met the criteria for informed decision‐making at baseline, the difference between the SMART and no SMART groups was not statistically significant.

Conclusion

Participation in a theory‐driven program to enhance gist reasoning may have a beneficial effect on informed decision‐making among patients with inadequate knowledge concerning therapeutic options.

Mediators of the association of limited English health literacy with medication non-adherence among Singaporean elderly

Background:

In Singapore, English is predominantly used on prescription medication labels (PMLs). However, many older Singaporeans cannot read English, and among those who read English, their English health literacy (EHL) proficiency varies. It is thus pertinent to examine the link between EHL and medication use outcomes in this population. The present research aims to address this question.

Methods:

Data from a national survey, on 1167 home-dwelling elderly on ⩾1 prescribed medication was analysed. The validated Health Literacy Test for Singapore was used to determine EHL. Medication non-adherence was self-reported. Path analysis examined the association between limited EHL and medication non-adherence and tested possible mediators.

Results:

Limited EHL was associated with medication non-adherence (total effect=0.35; p-value: 0.032), and ‘uncertainty in taking medications correctly due to difficulty in understanding written information on PMLs’ was a significant mediator (indirect effect=0.23, 95% confidence interval (0.12–0.39)).

Conclusions:

Elderly people with limited EHL were significantly more likely than those with adequate EHL to report that they were uncertain about taking medications correctly because they had difficulty understanding the information on PMLs and this misunderstanding contributed to medication non-adherence. Interventions focused on incorporating bilingual text and/or pictograms on PMLs may reduce uncertainty in taking medication correctly and improve medication adherence among the elderly.

Implementation fidelity of patient-centered prescription label to promote opioid safe use

PURPOSE

Patient-centered labels may improve safe medication use, but implementation challenges limit use. We assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording.

METHODS

As part of a larger investigation, patients received TWS prescriptions (eg, Take: 1 pill if you have pain; Wait: at least 4 h before taking again; Stop: do not take more than 6 pills in 24 h). Prescriptions labels recorded at follow-up were classified into three categories: (1) one-step wording (Take 1 pill every 4 h [without daily limits]), (2) two-step wording (Take 1 pill every 4 h; do not exceed 6 pills/day), and (3) three-step wording. There were three subtypes of three-step wording: (3a) three-step, not TWS (three deconstructed steps, not necessarily TWS wording), (3b) TWS format, employing three steps with leading verbs, but "with additions or replacements" (eg, replaced "do not take" with "do not exceed"), and (3c) verbatim TWS.

RESULTS

Two hundred eleven participants completed follow-up. Mean age was 44.3 years (SD 14.3); 44% were male. One-step bottles represented 12% (n = 25) of the sample, whereas 26% (n = 55) had two-step wording. The majority (44%, n = 93) had three-deconstructed steps, not TWS (3a); 16% (n = 34) retained TWS structure, but not verbatim (3b). Only 2% (n = 4) displayed verbatim TWS wording (3c). All category three labels (utilizing deconstructed instructions) were considered adequate implementation (62%).

CONCLUSIONS

Exact intervention adherence was not achieved in the majority of cases, limiting impact. Nonetheless, community pharmacies were responsive to new instructions, but higher implementation reliability requires additional supports.

Investigating the efficacy of an interactive warning for use in labeling strategies used by us pharmacies

Background

United States pharmacies repackage medications into multi-dose vials, enabling customized dosing for prescription drugs. Investment in infrastructure has made this the predominant approach to packaging for US prescriptions. Although recent changes to labeling now discourage the use of auxiliary labels (small stickers highlighting information germane to the safe and effective use), they are still allowed by USP<17>, provided their use comes from an evidence-based perspective.

Objectives

Evaluate how 'interactive,' placements of auxiliary labels (placement requiring physical manipulation of the warning to accomplish a task (e.g. opening)) garner attention as compared to those placed vertically or horizontally.

Methods

Ninety-six participants were eye tracked while opening three prescription vials (each with an auxiliary warning label with a different placement: vertical, horizontal and interactive). Recall and recognition were tested subsequently. Linear mixed models were used to analyze the continuous variables while the binary response variables were analyzed using generalized linear mixed models. The effect of auxiliary labels was fitted as a fixed effect and the subject-to-subject variation was considered as a random effect in the model. Participants' age, health literacy and sex were added to the models if their effect was statistically significant at alpha=0.05.

Results

The placement of the warnings significantly impacted the time spent viewing the information they contained at alpha=0.05; people spent significantly longer on interactive placements (0.96; SD 0.13 seconds) than either, horizontal placements (0.27; SD 0.037 seconds) or those placed vertically (0.18 seconds; SD 0.035). Participants were equally as likely to see information presented in an interactive placement (90%; SD 3.8) or horizontal placement (78%; SD 05.5) but less likely to view warnings placed vertically (60%; SD 6.9). Free recall responses also supported the use of interactive placement (62%; SD 6.8 recall) as compared to horizontal placements which were 29%; SD 3.0 and 20%; SD 6.0 for vertical placements.

Conclusions

Data provides evidence which suggests that interactive and horizontal placements out-perform auxiliary labels placed vertically on prescription vials with regard to garnering patient attention.

Best-practices for the design and development of prescription medication information: A systematic review

OBJECTIVE

To present evidence supporting best-practices for prescription drug labeling and educational materials.

METHODS

Articles were selected from three online databases (PubMed, Embase, CINAHL). Eligible manuscripts were: 1) English-language, 2) randomized, controlled trials, and 3) focused on improving prescription drug labeling practices.

RESULTS

Forty-nine articles were reviewed, and included both regulated label materials and pharmacy or health systems-generated tools. Best-practices included use of plain language principles, typographic cues, quantitative descriptors, and standardized formats, when applicable. Common outcomes included preference and comprehension, while few studies examined actual medication use (e.g. adherence, harms) or clinical health outcomes. Approximately half of studies directly engaged patients' perspectives in intervention development, which may have helped increase tool effectiveness.

CONCLUSIONS

Several best practices were apparent in the literature, particularly for written materials and pharmacy-generated container labeling. Design principles for supplemental instructions and multimedia tools were less cohesive, albeit less researched. The impact of patient involvement in tool design is promising, though requiring further study.

PRACTICE IMPLICATIONS

Definitive studies to inform practice standards on how to best communicate medication information to consumers are needed, especially as communication modalities continue to evolve. Increased research on if and how to incorporate patient-centered decision-making into the development process should be considered.

A narrative review on do's and don'ts in prescription label writing - lessons for pharmacists

Providing medicines information is a key role of a pharmacist. Miscommunication between pharmacist and patient may lead to adverse drug events or therapeutic failure. The aim of the review was to summarize the available research findings on factors that lead to poor communication between pharmacist and patient when providing written medicines information on dispensing and auxiliary labels and identify successful interventional approaches that help to alleviate these concerns. We selected articles available on PubMed, SAGE, and Google Scholar databases that are relevant to our objective. A total of 33 articles that matched the objectives of this review were retrieved and evaluated by all three authors. It was found that patient literacy levels, number of medicines dispensed, format and organization of the label, complexity of dosing instructions, precision of writing dosing instructions and use of icons, graphics and pictograms were aspects that were frequently used, and hence assessed by research groups on medicine label writing. Most studies reported that simple and straight forward instructions written legibly were better comprehended by patients. Based on our findings, we provide here useful tips for pharmacists on writing dosing instructions for patients. Finally, we spotlight crucial research gaps related to communicating written dosing instructions that need to be addressed in the future.

Patients' ability to read and understand dosing instructions of their own medicines - a cross sectional study in a hospital and community pharmacy setting

BACKGROUND

Poor communication of medicines information to patients may cause medication errors. We assessed the completeness and readability of dosing instructions provided by pharmacists on dispensing labels and knowledge among patients on dosing instructions of their medicines.

METHODS

A cross sectional study was conducted in a selected teaching hospital, and a community pharmacy, among 800 patients selected through a systematic sampling method, during a period of 2 months. Completeness of dosing instructions were assessed against a checklist. Patients were asked to read dosing instructions to assess readability. Patient knowledge on dosing instructions were determined through a questionnaire. Completeness, readability and knowledge were scored out of 10 for each dispensing label.

RESULTS

A total of 1200 and 1372 dispensing labels were assessed in the hospital and community settings respectively. The median score out of 10, for completeness, readability and patient knowledge of dosing instructions were 6.7, 8.3 and 7.5 respectively in the hospital, and 7.5, 8.0 and 7.5 respectively in the community. Only a few dispensing labels had the route of administration (hospital, 0.5%; community, 0.8%) and the duration of treatment written (hospital, 0.25%; community, 0.65%) on them. Name (hospital, 48%; community, 27.3%) and strength (hospital, 40.2%; community, 36.6%) of medicines on dispensing labels were frequently misread. In both settings, readability scores significantly differed with education level (P < 0.001).

CONCLUSIONS

Some important dosing instructions were missing in dispensing labels. Readability of dosing instructions by patients was also not 100% and differed by their education level. Pharmacists did not adhere to a standard procedure in providing dosing instructions leading to communication gaps with patients. Hence we recommend the development of a standard procedure to provide complete, clear and simple dosing instructions to patients, and continuous training for pharmacists on proper communication of dosing instructions to patients.

Under what conditions can a nonprescription drug label serve as refutation text? The role of directed attention and processing strategy

Nonprescription drug labels are relatively ineffective in refuting drug misconceptions. We sought to improve the effectiveness of an aspirin label as a refutation text by manipulating selective attention and label-processing strategy. After reading a facsimile label, those of 196 undergraduates who attempted to explain why shaded drug facts are "easily confused" recalled more refuting drug facts than participants who attempted to explain why those facts are "easily ignored." However, "easily confused" processing did not change truth ratings of misconceptions associated with those drug facts. We conclude that refuted misconceptions remain in memory but are inhibited by disconfirming drug facts.

What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study

BACKGROUND

Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels.

METHODS

Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing.

RESULTS

Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Participants also believed it would improve consumers' medication understanding and adherence. Prescribers and pharmacists believed it could help reduce prescribing and dispensing errors by matching the drug/dosage to the correct indication. Prescribers refrained from documenting the indication to protect patients' privacy; however, most patients did not consider documenting the indication as a breach of privacy. Prescribers raised concerns about the extra time to include indications on prescriptions and best language to document indications, using plain language as opposed to medical terminology.

CONCLUSIONS

All interviewed stakeholders identified numerous benefits of documenting the indication on prescriptions and dispensed medicines labels. Whether these potential benefits can be realized remains unknown and addressing prescribers' concern regarding the time involved in documenting the indication on prescriptions remains a challenge for vendors of electronic medication management systems.

Pharmacists and patients feedback on empirically designed prescription warning labels: a qualitative study

Background Recommendations call for the inclusion of both patient and provider input in the redesign of prescription labels. Pharmacist opinions on prescription warning labels are important because they are the health providers who would eventually distribute and explain the revised labels during medication counseling. They may be the first health provider to notice a patient's misunderstanding on how to safely use their prescription medications. Objectives To explore the perspectives of patients and pharmacists on five newly designed PWLs, and examine if there were similarities and differences between patients' and pharmacists' perspectives. Setting Private room in Wisconsin. Methods A descriptive study using semi-structured 60-min face-to-face individual interviews with patients and pharmacists explored patients and pharmacists' feedback on five newly designed PWLs. Patients who were 18 years and older, spoke English, and took a prescription medication and pharmacists who filled prescriptions in an ambulatory setting participated in the study. The patient and pharmacist perspectives on the words (content), picture and color (cosmetic appearance), and placement of warning instructions on the pill bottle (convenience) was based on a label redesign framework. Qualitative content analysis was done. Main outcome measure Patient and pharmacist perspectives on the newly designed PWLs. Results Twenty-one patients and eight pharmacists practicing in an academic medical center outpatient setting (n = 5) or retail pharmacy (n = 3) participated. All patients and pharmacists wanted the PWLs positioned on the front of the pill bottle but not the side of the bottle or warning instructions embedded into the main prescription label. Other similarities included participants preferring: (1) pictures closely depicting the instructions and (2) the use of yellow highlighting on the PWL to draw attention to it. There were differences in patient and pharmacist perspectives regarding the addition of 'Warning' to the instruction on the PWL with the patient preference to include the word 'Warning'. Pharmacists thought some PWL pictures had racial stereotypes, but this feedback was never mentioned by patients. Conclusions Patients and pharmacists had different preferences for PWL design changes to improve understandability. Pharmacist preferences did not always correspond with patient preferences. However, patients and pharmacists generally agreed on the preferred location of the PWL on the pill bottle and the use of color for drawing patients' attention.

Comprehension by older people of medication information with or without supplementary pharmaceutical pictograms

This study examined the benefits of pharmaceutical pictograms for improving comprehension of medication information for older people. Fifty Hong Kong Chinese older people completed a medical information comprehension task for five drugs. Participants in the control group were presented with text labels while those in the experimental group were given the text labels plus supplementary pharmaceutical pictograms, and then all reported their understanding of the medication information conveyed. Lower educated older people had poorer understanding of medication information. The addition of pharmaceutical pictograms significantly improved the comprehension of medication information for older people. The majority of older people tested with pictograms favored adding pictograms to text and thought the pictograms were useful for conveying medical information rather than using written text alone. The findings suggested that pharmaceutical and health care professionals should include pharmaceutical pictograms on labels to better convey instructions on medication to older people.

Refining Prescription Warning Labels Using Patient Feedback: A Qualitative Study

The complexity of written medication information hinders patients' understanding and leads to patient misuse of prescribed medications. Incorporating patient feedback in designing prescription warning labels (PWLs) is crucial in enhancing patient comprehension of medication warning instructions. This qualitative study explored patient feedback on five newly designed PWLs. In-depth semi-structured face-to-face interviews were conducted with 21 patients, who were 18 years and older, spoke English, and took a prescription medication. These patients were shown different variations of the five most commonly used PWLs-Take with Food, Do not Drink Alcohol, Take with a Full glass of Water, Do not Chew or Break, and Protect from Sunlight. The 60-minute interviews explored feedback on patient comprehension of the PWL instructions and their suggestions for improving the clarity of the PWLs. At the end of the interview, patient self-reported socio-demographic information was collected with a 3-minute survey and a brief health literacy assessment was completed using the Newest Vital Sign. Twenty-one patients completed the interviews. Most patients were female (n = 15, 71.4%) with ages ranging from 23 to 66 years old (mean: 47.6 ± 13.3). The mean health literacy score was 2.4 on a scale of 0-6. Qualitative content analysis based on the text, pictures, and placement of the PWLs on the pill bottle showed preferences for including 'WARNING' on the PWL to create alertness, inclusion of a picture together with the text, yellow color highlighting behind the text, and placement of the PWL on the front of the pill bottle. Although patients had positive opinions of the redesigned PWLs, patients wanted further improvements to the content and design of the PWLs for enhanced clarity and understandability.