blog post 01162017

Health Literacy and Medication Errors Are No Laughing Matter

By Katie Owens, Vice President, HealthStream Engagement Institute

More than 80% of parents made a mistake giving their children medication in a recent Yale University School of Medicine study1. Medication errors represent very real dangers that kill thousands each year. Unfortunately, health literacy is often a contributing factor leading to medication errors, such as not understanding dosage, side effects, or not complying with the prescribed regimen. Health.gov2 estimates staggering rates of health literacy challenges, suggesting that only 12% of adults have proficient health literacy levels (Chart 1).

To understand ways to improve medication safety, it is essential for caregivers to understand the state of health literacy in the United States. You cannot assess individual health literacy on sight, nor can we assume that silence or a nod equates to understanding or demonstrates the patient’s ability to actively follow through with care processes. Health literacy (or the lack thereof) can impact everyone—regardless of age, educational status, race, income, etc.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey gives us significant insight into the patient voice3. Current responses reveal that only 65% of patients can say that staff “always” explained medicines before giving it to them. That means 35% of the time we are inconsistent in communication about one of the most important elements of a person’s well-being following medical care. 

What can you do?

While this topic is worthy of a book or a two-hour discourse, here are some pragmatic ideas for organizations to improve:

  • Cultivate competencies for medication communication in a way that encourages interprofessional ownership and collaboration.
  • Leverage the HCAHPS Survey Medication Communication domain and Items to set goals and evaluate progress and build action plans with your staff. The HCAHPS questions include:
    1. How often did hospital staff tell you what the medicine was for?
    2. How often did the staff describe possible side effects in a way you could understand?
  • Keep it simple and use whiteboards! Painstakingly evaluate what you say and the word choices to describe healthcare jargon. Challenge your teams to replace industry-specific healthcare words into ones your loved ones would understand.



Patient-Centered Words


High Blood Pressure






By mouth

  • Use RELATESM as a Patient-Centered Communication Model

Relate for Medication Management

  • Empower patients to speak up when they don’t understand. Using the National Patient Safety Foundation (NPSF) Ask 3 can build a patient’s confidence and competence. Teach patients to be inquisitive and to ask such questions as: 
    1. What is the name of that medication?
    2. Why do I need to take it?
    3. What are the possible side effects of that medication?
  • Consider a telephone patient experience survey and discharge call. Surveys such as HealthStream’s Patient Insights offer telephone-based surveys that eliminate literacy gaps and Cipher Health’s echo tool offers patient care follow up to support discharge instruction efficacy.

A New Approach to Improving Health Literacy and Medication Communication

As a final note, many of us in healthcare have felt or seen the avoidable and unnecessary repercussions of poor health literacy and medication errors. Let’s take this opportunity to recognize that this issue has two very distinct sides that need to be merged to gain perspective. Take time to acknowledge “our” perspective as caregivers and the needs of our patients from their perspective. Remember, on a moment’s notice patients have had their lives changed or are grappling with chronic diseases. A dose of empathy goes a long way to creating a shared perspective and mutual engagement to solve this problem in healthcare. 

Patient vs. Provider Perspective

Learn more about HealthStream’s solutions for improving patient experience and outcomes.


  1. Bakalar, N. Most Parents Give the Wrong Dose of Liquid Medication. New York Times. September 12, 2016. Retrieved from:
  2. America's Health Literacy: Why We Need Accessible Health Information. An Issue Brief From the U.S. Department of Health and Human Services.
  3. Centers for Medicare and Medicaid. Hospital Compare. Retrieved from:

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