The Institute of Medicine Identifies "Health Illiteracy" as a Root Cause of Medical Error

The Institute of Medicine (IOM) issued a report on April 8, 2004 [IOM Health Literacy: A Prescription to End Confusion] stating that as many as 90 million American adults lack the reading and math skills needed to understand basic health information and navigate the U.S. healthcare system. The IOM identified a conceptual entity with their new title called "Health Literacy: a prescription to end confusion".

The IOM report specified that the list of skills required for a U.S. citizen to be health literate are reading, writing, listening, speaking, arithmetic, and conceptual knowledge. The IOM defined health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health." At some point, most individuals - even the well educated with strong reading and writing skills - encounter some health information regarding forms, a drug or a procedure that they don't understand. Aside from calling for the health care system to address the problem through improved health education, the IOM put the onus on physicians and other health care providers to listen to their patients to discern whether they have understood what they needed to know to participate in their disease management and/or improve their health status with preventive measures.

In my professional experience I have encountered thousands of patients in the home environment over two decades. Most of the people I interviewed who were on medications did not know the names of their drugs, or the potential side-effects. All they knew for the most part was the color, shape and what disease it was for (i.e. high blood pressure, diabetes, nervousness or infection)

There are two basic areas of concern in the IOM report. The first one is public awareness of where to go for which problems. This is a matter of public education and deals with the population before they enter the system and encounter a health provider. The second area of concern is the information provided by the physician or other health practitioner. This applies to individuals who are under the care of the particular health provider, be it a physician, nurse practitioner, chiropractor, H.M.O., home infusion company, etc. The IOM attributes the failure to ensure that patients understand enough to participate in their own care as a major cause of medical mistakes.

Therefore, part of the duty that a licensed health practitioner owes is to make certain that patient or responsible party understands the information that must be provided to the extent that the patient or significant other can participate in managing the illness and engage in preventive measures.

Case in point 1:

In the first case, a man living in the USA who was not proficient in English received a prescription for Tylenol with codeine. The label read: "1 or 2 tablets every 3 hours as needed for pain". The patient understood this to mean that he could take two tablets every 3 hours or more often as needed. He ended taking two tablets every hour until he collapsed from a narcotic overdose. He survived with a mild degree of anoxic encephalopathy (brain damage from lack of oxygen). The patient sued contending that it would have been a simple matter to ask the patient, "What is your understanding of the instruction regarding your pain pills?" and not doing so was unreasonable.

Although many would argue that people must take responsibility for misunderstanding simple directions, the IOM points out that approximately ninety million people in America are unable to understand medical directions as provided on labels, instructions and verbally. On the other hand, one can also argue that people know whether they understand something or not and if not, they still have the responsibility of asking for further explanation. However, the core of the problem in poor communication is not lack of understanding but misunderstanding. Health-illiterate patients most often walk away from a consultation not realizing that they have an erroneous set of instructions in mind that differs from what the health practitioner said.

Therefore, it is incumbent upon the health care provider to take a reasonable step to be certain that the patient received and understood the medical advice correctly. Additionally we need to take a look at the standard instructions such as "take one or two tablets every three hours as needed for pain" and perhaps change it to "take one or two tablets three hours or less often as needed for pain."

Case in Point 2

The second case involves a 63-year-old man who was sent home from the hospital on intravenous Morphine delivered via patient controlled analgesia (PCA). The man died of an overdose on the second day of the infusion despite the fact that his wife was checking on him frequently through the whole time. In the investigation that followed, it was apparent from the records that the home infusion intake nurse failed to provide sufficient teaching to the patient's wife. The wife simply looked at her husband, who was asleep most of the time, and thought he was okay because he was breathing and sleeping peacefully. She obviously did not possess enough health literacy to check for narcotic stupor by waking him up and seeing whether he was difficult to arouse. She needed to find out whether he could respond to voice, or required tactile or even painful stimulation to wake up. The nurse needed to make certain that the wife understood how to assess level of consciousness. It is likely that with a few extra moments of effective communication, the wife would have been able to know that her husband was in trouble and she would have dialed 911 soon enough to save his life.