Medication Safety: Confirming Patient Understanding: "Tell Back" Works Best

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

Over the past few years, multiple studies have demonstrated that patients often leave medical encounters with a poor understanding of their health conditions and recommended treatment. One published study on this subject demonstrates the low level of understanding patients have about follow-up care and medication therapy upon discharge from the emergency department.¹

One incident reported to the Institute for Safe Medication Practices illustrates this point. A patient was taking warfarin 5 mg daily. Routine lab work reported that his international normalized ratio (INR) was slightly elevated. The prescriber decided to change the patient’s dosing regimen to warfarin 5 mg alternating with warfarin 2.5 mg on opposite days to bring the INR down into a therapeutic range. The patient was informed of the change in dosing by the prescriber’s receptionist/assistant. She instructed the patient to take “5 one day and 2½ the next day.” The patient interpreted this to mean, however, that he should take 5 tablets (25 mg) one day and alternate with 2½ tablets (12.5 mg) the next day. The patient developed gastrointestinal (GI) bleeding and was admitted to the hospital with an INR >20 and hemoglobin of 6.8 g/dL. Thankfully, the patient survived.

Given the importance of a patient’s understanding of medical information, surprisingly few studies exist that point out how to approach this task. One study offers some insight into what approach patients most prefer and perceive to be the most effective to assess understanding of medical information.² Researchers tested 3 types of inquiry about the patient’s understanding: Yes- No; Tell Back-Directive; and Tell Back- Collaborative.

The Yes-No approach asked closedended questions to assess patient understanding (eg, “I have given you a lot of information. Do you understand?”). The Tell Back-Directive method used open-ended questions that were physician-centered and paternalistic, in that it was clear authority and control still remained with the physician (eg, “It is really important that you do this exactly the way I explained. What do you understand?”). The Tell Back-Collaborative approach used open-ended questions that were patient-centered, making it clear that power and responsibility were shared between the health care provider and patient (eg, “I imagine you are really worried about this clot. I have given you a lot of information. It would be helpful to me to hear your understanding about your clot and its treatment”).

Patients showed a significant preference for the Tell Back-Collaborative inquiry over other tested approaches. Because of the potential for embarrassment if patient misunderstandings are exposed, one might anticipate health care providers’ reluctance to put patients “on the spot” with open-ended questions. The collaborative approach to Tell Back allows the patient to save face for misunderstandings by acknowledging the large amount of information being provided. Patients might also view the request for Tell Back as evidence of the health care provider’s care and concern for them personally.

When educating patients and their caregivers about their medications, instead of asking “Do you have any questions?” or “Do you understand?,” ask them to restate their understanding of the information you provided in their own words within a shame-free environment. It is critical that patients and/ or caregivers be able to recite back the information they received on how to properly take their medications, rather than just be given a leaflet or be asked if they have any questions. â– 

References

1.

Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53(4):454-461.e15.

2.

Kemp EC, Floyd MR, McCord-Duncan E, Lang F. Patients prefer the method of “tell back-collaborative inquiry” to assess understanding of medical information. J Am Board Fam Med. 2008;21(1):24-30.

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Pharmacy Times and the Institute for Safe Medication Practices (ISMP) would like to make community pharmacy practitioners aware of a publication that is available. The ISMP Medication Safety Alert! Community/ Ambulatory Care Edition is a monthly compilation of medication-related incidents, error-prevention recommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscription prices are $52 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, send an e'mail message to community@ismp. org, or contact ISMP at 215-947-7797.