Medication Safety: "Comprende" Not Necessarily

APRIL 01, 2009
Michael J. Gaunt, PharmD

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.

Many people have trouble adhering to a prescribed plan of care. Some limits occur as a result of emotional distress, clinical condition, or socioeconomic factors. Pharmacists, however, also should consider the possibility that poor health literacy is a barrier to adherence for many patients. Older patients, people with chronic diseases, and patients who do not speak English as their primary language, or at all, are especially likely to exhibit low health literacy.

ISMP received a report from a community pharmacist who works in a setting where 90% of her patients are Spanish-speaking. An elderly man, who did not speak or read English, returned to the pharmacy for more information after having taken a portion of a methylprednisolone dose pack. He had not received appropriate instructions about how to administer this complicated dosing regimen, and he was not taking the medication correctly. Fortunately, the gentleman was not harmed, but he did not receive the full intended benefits of the drug either.

Studies have shown that 36% of Americans function at the basic health literacy level or lower.1 It is even more significant (66%) for Americans of Hispanic race/ethnicity. Furthermore, a national managed care organization study described the literacy of 54% of Spanish-speaking Medicare enrollees to be inadequate or marginal.2

Keep in mind, too, that not all patients who speak Spanish can understand medication instructions written in Spanish. A 2004 study among Spanish-speaking Latino parents with limited English proficiency who were given prescription labels in English and corresponding medication information leaflets in Spanish exemplified this fact.3 The parents were asked to read the medication label and the information sheet and then answer questions regarding the medication and proper dosing. Of the 100 study participants, only 22% would have given a correct dose of medication to their child. In addition, only 29% were able to answer questions regarding the medicine dosage and proper use as a result of having access to written information in Spanish. Also noteworthy in the study was the fact that even among individuals who self-described themselves as being comfortable speaking English, only 50% were able to demonstrate knowledge that would allow them to accurately prepare a dose of their child’s medication.

Safe Practice Recommendations

In order to help individuals of this patient population use medications safely, a number of interventions must be employed. Here are some suggestions that can make patient education sessions more successful.

  • Assess a patient’s level of comprehension. The Short Assessment of Health Literacy for Spanish-speaking Adults, a screening tool, identifies Spanish-speaking adults with low health literacy.4 Notations should be made in these patients’ profiles and charts to alert practitioners and foster supplemental education for these patients at each follow-up visit.
  • Supply language-appropriate patient information. Consider placing Spanish-speaking pharmacists in areas with a high percentage of Spanish-speaking patients. In practices with fewer Spanish-speaking patients, forge a working relationship with a pharmacist who is fluent in Spanish to assist in patient counseling. Also, the National Library of Medicine and the National Institutes of Health ( have easy-toread medication information leaflets in both English and Spanish.
  • Provide small amounts of verbal information at a time. First, in simple everyday language, tell patients what they truly need to know to take their medications safely and to identify important side effects. Emphasize desired behavior, not the medical facts. Leave extensive overviews of interactions and side effects for later encounters. Avoid using medical terminology and jargon.
  • Use multimedia visuals. Another strategy to consider for patients with low health literacy is the use of multimedia visuals aids, such as video, audiotapes, and CDs, preferably in the patient’s primary language.
  • Verify patients' understanding. Use the Teach-Back Method to counsel patients. Avoid asking “yes” or “no” questions. Instead, ask patients to show and tell you, in their own words, how they would take their medicine.


  1. Kutner M, Greenberg E, Jin Y, Paulsen, C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). US Department of Education. Washington, DC: National Center for Education Statistics. 2006.
  2. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551.
  3. Leyva M, Sharif I, Ozuah PO. Health literacy among Spanish-speaking Latino parents with limited English proficiency. Ambul Pediatr. 2005;5(1):56-59.
  4. Lee SY, Bender DE, Ruiz RE, Cho YI. Development of an easy-to-use Spanish Health Literacy test. Health Serv Res. 2006;41(4 Pt 1):1392-1412.