A Prescription for misunderstanding: Opportunities for misinterpretation along the information flow from physician to patient

Abstract

Background: Medication errors are costly in both human and financial loss. Interpretations of prescription instructions have been found to vary considerably, including discrepancies between patients and prescribing physicians.

Objective: Identify discrepancies in interpretation of prescription instructions between healthcare consumers, nurses, and physicians

Method: Research Design: Cross-sectional study; Setting: Large university, 2 hospitals and various clinics in Mississippi and Florida; Participants: 74 young healthcare consumers, 34 RNs, and 36 physicians; Measures: Questionnaires asking for interpretations (i.e., what times would/should you take the drug) for various prescription instructions were provided to healthcare consumers, nurses, and physicians.

Results: There was considerable within-group variability in the interpretation of prescription instructions by all groups including physicians. Moreover, physicians, nurses, and healthcare consumers exhibited between group variability in their interpretation of prescription instructions. None of the instructions were uniformly interpreted and a fair number of consumer and nurse interpretations resulted in potentially unsafe schedules of drug administration. Some physicians and nurses also apparently lacked awareness of the potential for interpretation variability.

Conclusions: Because two healthcare providers can have different intentions for identical instructions, an awareness and subsequent education of potential sources of misinterpretation is vital. The present results indicate a need to identify and explore within-group variability of intent among physicians and other healthcare providers.