US Pharm. 2009;34(6):11. 

Many people have trouble functioning well as patients. Whether limited by knowledge, emotional state, or socioeconomic factors, their level of health literacy—the ability to read, understand, and act on health care information—is often dangerously low. Older patients, people with chronic diseases, recent immigrants, and patients who do not speak English as their first language or at all are especially vulnerable to low health literacy. The Institute for Safe Medication Practices recently received a report from a community pharmacist who works at a store where 90% of her patients speak Spanish. An older man returned to the pharmacy after having received a methylprednisolone dose pack and said he did not understand how to take it; he did not read or speak English. He had already taken some of the medication incorrectly but luckily was not harmed. 

Studies have shown that of the 63 million Americans functioning at the basic (5th grade) reading level, 39% describe themselves as Hispanic.1 Another study from a national managed care organization found the literacy of 54% of the Spanish-speaking Medicare enrollees to be inadequate or marginal.2 

Pharmacists should not assume that Spanish-speaking patients who seem comfortable speaking English will understand a prescription label written in English, or that patients who speak Spanish will understand medication instructions written in Spanish. This fact has not gone unnoticed by the community pharmacist noted above. She has observed that “this particular population will say they understand what you go over with them, but they really don’t.” 

In a 2004 study, Spanish-speaking Latino parents with limited English proficiency were given prescription labels in English and corresponding medication information leaflets in Spanish.3 The parents were asked to read both the label and the information sheet and then answer questions regarding the medication and proper dosing for their child. Of the 100 participants in the study, only 22% would have dosed the medication correctly, and only 29% were able to answer questions regarding the medicine dosage and use from the Spanish-language leaflet. Additionally, of the subjects that reported they were comfortable speaking English, only 50% were able to demonstrate the correct amount of medication to administer to their child. 

Safe Practice Recommendations

While providing printed drug information in a patient’s native language is important, more tools need to be employed to help this unique population use medications safely. 

Offer small amounts of verbal information at one time. In simple everyday language, tell patients what they truly need to know to follow directions. Avoid using medical terminology. Emphasize desired behavior, not the medical facts. Leave background information for later encounters. 

Verify that the patient understands. Use the “Teach Back” Method for counseling low literacy patients. Avoid asking Yes or No questions and instead have patients show and tell you how they would take their medicine so that you can spot problems. Patients and caregivers should be asked to demonstrate their knowledge and comprehension by repeating instructions in their own words. For safety, have patients or caregivers demonstrate how they will measure the dose and administer the drug using the actual product, drug delivery device, or a mock-up. 

Assess the patient’s level of comprehension. A screening tool, the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), has been developed to assess comprehension levels of common medical terms among Spanish-speaking people.4 Identifying these patients will alert pharmacists and other health care providers that supplemental education will be needed. Pharmacists’ increased awareness to the special health care needs of the low-health literacy, Spanish-speaking population will help prevent medication errors due to dosage and indication misunderstandings by patients or caregivers. 


1. Barnett CW. Patient health literacy in the community setting. Am Pharm. 2006;12:64.
2. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545-551.
3. Leyva M, Sharif I, Ozuah PO. Health literacy among Spanish-speaking Latino parents with limited English proficiency. Ambul Pediatr. 2005;5:56-59.
4. Lee SY, Bender DE, Ruiz RE, Cho YI. Development of an easy-to-use Spanish health literacy test. Health Serv Res. 2006;41:1392-1412.

This column was prepared by the Institute for Safe Medication Practices (ISMP). ISMP is an independent nonprofit agency that analyzes medication errors, near misses, and potentially hazardous conditions as reported by pharmacists and other practitioners. ISMP then makes appropriate contacts with companies and regulators, gathers expert opinion about prevention measures, and publishes its recommendations. To read about the risk reduction strategies that you can put into practice today, subscribe to ISMP Medication Safety Alert!® Community/Ambulatory Edition by visiting ISMP is a Federally Certified Patient Safety Organization, providing legal protection and confidentiality for submitted patient safety data and error reports. ISMP is also a Food and Drug Administration (FDA) MedWatch partner. Call 1-800-FAIL-SAF(E) to report medication errors to the ISMP Medication Errors Reporting Program (MERP) or report online at ISMP address: 200 Lakeside Dr, Suite 200, Horsham, PA 19044. Phone: 215/947-7797. E-mail:

To comment on this article, contact