What’s on a label? This simple intervention could improve patient safety and save money

My patient’s daughter unfolded a pizza box and propped it up on the chair next to her. In thick, black Sharpie letters three inches high, “breakfast,” “afternoon” and “before bed” were inscribed between faded grease stains. The names of about a dozen medications were listed under the headings. Some letters were underlined, like the “p” in bisoprolol.

“It works well for her!” her daughter said of her mother’s setup. “My mom keeps this propped up on her kitchen table and refers to it every time she takes her medications.” Probing about the potential value of a medication blister pack, she scoffed: “We tried a pill box on a recent trip. It went terribly. My mom forgot to take her medications four times.”

This interaction highlights the struggle that many medication users and their caregivers face. Medications often have long, difficult to pronounce names (e.g., sacubitril/valsartan), and have both trade and generic names used variably between pharmacists and physicians. Research indicates that only 64 per cent of patients could correctly identify why they were taking their medications post-discharge from a hospital internal medicine unit.

Part of this gap could be filled by adding crucial missing information on medication labels – the reason for its use, which refers to the symptoms or the disease process that a medication was prescribed to treat, and can include things like managing pain, reducing blood sugar, treating depression or preventing heart failure exacerbation. This reason for use also can be shared on prescriptions sent to pharmacists, giving them more confidence in truly knowing why a patient is taking a given medication versus simply relying on the patient-reported indication.

Prescribers acknowledged that adding a reason for use could benefit their pharmacist colleagues.

Adding reason for use is not mandatory on prescriptions in Ontario and is rarely included but patients, prescribers and pharmacists all see the value in adding it to prescriptions and medication labels.

Pharmacists saw the addition as a way to loop them in more closely to the rest of the patient’s health-care team. It also would allow them to reduce guesswork when counseling patients and support them in assessing the safety of a given medication. Prescribers generally acknowledged that adding a reason for use could benefit their pharmacist colleagues. However, they were hesitant to add another piece of information to their prescriptions, noting the already marked administrative burden they have when completing tasks relating to patient care.

Patients noted how including this information would better allow them to link their medications to their symptoms. Patients also shared that it would allow for better continuity when a medication brand is changed and allow them to better participate in decision-making.

One drawback may be privacy concerns, with patients overwhelmingly wanting to have a say on adding reason for use to their medication labels (one called it a “public display” of their illness). However, preliminary results from an ongoing study demonstrate patients generally prefer vague language when describing the reason for use for medications to treat sensitive illnesses. For a diagnosis of major depressive disorder, for example, language like “for mood” and “for mental health” was generally preferred over “depression.”

Sharing reason for use is an opportunity to support patient health literacy and to improve communication within the health-care team. Evidence shows health literacy is related to outcomes like readmissions, medication errors and even all-cause mortality. Therefore, there is significant potential for this simple intervention to make care safer and more cost effective.

Maybe we can even make pizza-box medication systems obsolete once and for all.

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Colin Whaley


Colin Whaley is an incoming internal medicine resident physician at the University of Toronto and is a final year medical student at McMaster University. He previously completed a Master of Science in Pharmacy at the University of Waterloo, evaluating the addition of a medication’s indication on prescriptions and medication labels.

Brandon Tang


Brandon Tang is a fifth-year General Internal Medicine subspecialty resident physician at the University of Toronto. Throughout his training, he has been engaged in education leadership and advocacy, including serving as Chief Resident for the International Conference on Residency Education and a deputy editor at Healthy Debate. He is currently pursuing a Master’s in medical education through Harvard Medical School. You can follow Brandon on Twitter at @DrBrandonTang.

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