A RETIRED TRUCK DRIVER, Mr. J, 66, was recently discharged after in-hospital treatment for exacerbation of his chronic obstructive pulmonary disease. Recently widowed, he lives alone and has visual impairment secondary to age-related macular degeneration.
After picking up his new prescription, Mr. J realized that he couldn't read the directions on his medication bottle. "I thought it said to take five tablets once a day, but that didn't sound right," said Mr. J. "So I just guessed and decided to take three tablets every morning and two every evening." Mr. J expressed his frustration with his physician and nurses for not communicating his visual impairment to the pharmacy, which resulted in a missed opportunity for pharmacist consultation.
Mr. J wasn't harmed by this vision-related medication error, but it illustrates the potential for a serious error when patients have impaired vision. According to the Institute for Safe Medication Practices, one vision-related medication error resulted in death after a patient misread the directions on a prescription bottle and took four methotrexate tablets every "morning" instead of every "Monday."1
This article provides practical nursing interventions and patient-education tips to help nurses steer patients with visual impairment clear of such dangerous medication errors.
Focusing on the risks
Mr. J is one of 14 million visually impaired Americans.2 The World Health Organization estimates that 285 million people are visually impaired worldwide. Of these, 39 million are blind and 246 million have low vision.3 (See Clarifying terms.)
Visually impaired patients may experience difficulty differentiating among their medications. Small font size may make it difficult for them to read storage, dosing, and administration instructions. They may also have trouble assembling and using medical equipment, including glucometers and BP machines. Many visually impaired patients live with a caregiver, but patients like Mr. J who live alone face special challenges.
According to the FDA, over 1.3 million people in the United States are injured each year due to medication errors.4 Because patients with vision impairment are especially vulnerable to medication errors, patient education in this high-risk population can have a dramatic impact on patient safety.
Nursing considerations
Patients with visual impairment don't always assertively communicate their needs to nurses and other healthcare practitioners. Proactively assess patients' visual capabilities. If your patient has visual limitations, clearly communicate those limitations to other nurses, healthcare providers, and hospital staff involved in the patient's care. Encourage patients to tell you what they can see and to be assertive about expressing their needs.
As healthcare professionals, we need to remember to evaluate our patients' vision starting with hospital admission. Assess how well your patients can navigate the surroundings. Talk with them about their daily activities at home. For example, can they read food labels? Do they drive? If so, do they have trouble seeing road signs? This conversation provides a good segue into discussing home medication practices and helps you to assess whether those techniques are effective and safe.
Nurses need to sit down with the patient and family and take the time to teach them about discharge instructions, especially newly prescribed medications. With the push to expedite discharges, this step is often rushed, and the patient may leave without feeling confident about how to properly take medications. As nurses, we need to have a face-to-face discussion about each medication in detail. We should highlight the drug's name, reason for taking the drug, and drug dose, as well as how and when the patient is to take the medication. (For more help, see What medication assistive devices are available?) Then be sure to document your teaching.
Special techniques are very important for visually impaired patients. Ask your patient to read the medication instruction sheet to you so you can evaluate whether the font needs to be increased. Don't use italics, all capitals, or underlining, as these make reading more difficult for those with low vision. White or pale yellow paper with bold black lettering works best. Finally, always remember to keep your instructions simple.5
Patient-education tips
Give visually impaired patients these medication counseling tips to keep them safe at home:
* Create your own system to help keep track of your medications. One inexpensive option is to mark the bottles with differing numbers of rubber bands or ribbons. That way, you can identify the correct medication based on how many rubber bands or ribbons you can feel. Or, you could use the number of bands to represent how many times a day you have to take the medication.6
* Place medications in alphabetical order and store them where you actually take them (for example, keep evening medications on the nightstand and morning medications on the breakfast table).7
* Keep a light or magnifying glass near where you take your medications each day.8
* Purchase a Braille label maker to label your medications.7
* The shapes and sizes of different medications can aid in identification. Practice feeling different pills and/or the packaging they come in until you can recognize them.8
* Separate medications that you take infrequently from those you take daily.7
* Place medications on separate shelves in the medicine cabinet.7
* Ask your pharmacist to print a label with larger font size that you can easily read or in Braille if possible and appropriate. Then mark your medication bottles with these large-print or Braille labels, tactile dots, or rubber bands.9
* Use audible medication label readers if large-print labels don't work for you.9
* Use a tray with good contrast to help you see your pills easily and to help keep them from falling on the floor if any are accidentally dropped.8
* Attach dosing trackers (such as rubber bands or stickers) to medication bottles to help you remember if you've taken each dose of a particular medication.9
* Color code the medication bottles by using colored markers to help you identify them.
Special insight
Proactively searching for signs of impaired vision in patients can help nurses identify those individuals at increased risk for experiencing a medication error due to blindness or low vision. Through careful assessments and patient teaching, nurses in many settings can help vulnerable patients with visual impairments avoid experiencing medication errors at home.
Clarifying terms
* Low vision. "A person with low vision is one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 [meters] to light perception, or a visual field of less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for planning and/or execution of a task."10
* Blindness. "Visual acuity of less than 3/60 [meters], or a corresponding visual field loss to less than 10 degrees, in the better eye with the best possible correction."11
What medication assistive devices are available?
* pill boxes with raised lettering or Braille designating day of the week and time of day
* automated pill-dispensing machines
* audible pill boxes that sound an alert when it's time to take medication
* syringe magnifiers or insulin syringe guides
* "talking" pill reminders
* audible glucometers and BP machines
* prescription label readers that use radio frequency identification (RFID) technology to detect a microchip embedded within the prescription label. The microchip possesses pertinent prescription information for that prescription. When the prescription label (with embedded microchip) is placed over the reader, the speaker projects the prescription label information out loud to the patient.12 RFID compatible prescription labels are available via mail order from some large chain pharmacies.
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