Variations in Interpretation of Prescription Instructions

Abstract

Sixty-seven patients interpreted instructions on each of ten prescription labels. Not once was a label uniformly interpreted by all patients. Besides variability in the interpretation of imprecise instructions, frequent misinterpretation of explicit instructions occurred. With five prescriptions whose instructions were not ambiguous, the frequency of interpretive errors ranged from 9% to 64%. These observations illustrate the need for physicians to provide medication instructions that are consistent with the patient's daily activities and to review these instructions with the patient.