After a doctor prescribed a pain patch for a woman with arthritis, the patient started slurring her words. She put patches on her skin everywhere she hurt, her family discovered, not just in one place.
For a patient with epilepsy, a doctor changed a prescription from one, 1,000-milligram tablet twice a day to two 500-milligram tablets twice a day.
The patient kept taking one tablet twice a day, and subsequently had a seizure.
Drug labels can be confusing, especially for people who are elderly or not fully literate. Wisconsin Health Literacy is working with pharmacies to introduce new labels based on national guidelines that emphasize key information, clear instructions and readability.
“Our goal is to improve the labels so they’re easier to understand and people are able to more effectively use their medications,” said Steve Sparks, director of Wisconsin Health Literacy, part of Madison-based Wisconsin Literacy.
In a survey by the nonprofit this year of more than 700 patients, 88 percent said they have found drug labels difficult to understand. Nearly 23 percent said they have taken prescriptions incorrectly because of confusing labels.
Some of the patients joined health care providers in submitting stories like those involving the arthritis and epilepsy patients. Another anecdote: An elderly woman inadvertently took her husband’s heart medicine because it was an oval white pill, just like her diabetes drug prescribed by the same doctor.
Medication mistakes can result in emergency room visits, hospital stays and even death, Sparks said. The more prescriptions people take, the more opportunity for error.
Through a pilot program started last year, Wisconsin Health Literacy has been introducing new labels at more than 60 pharmacies at UW Health, Hayat Pharmacy, Hometown Pharmacy, Forward Pharmacy and Fitchburg Family Pharmacy.
On old labels, the pharmacy’s name, address and phone number often were on top, followed by a prescription number or the doctor’s name.
The new labels, based on standards from U.S. Pharmacopoeia, emphasize the patient’s name, the drug name (brand and generic) and its strength. Large, bold print is suggested, in a familiar font — such as Roman or Arial.
Explicit instructions, using numerals and no abbreviations, are stressed. Instead of, “Take two tabs twice daily,” the new labels say, “Take 2 tablets in the morning and 2 tablets in the evening.”
Now, Wisconsin Health Literacy plans to expand the program to more pharmacies around the state, in part by compiling an implementation guide. The larger rollout is supported by a $446,000 grant awarded last month from the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin.
The same fund contributed $256,000 earlier, and the UW School of Medicine and Public Health’s Wisconsin Partnership Program has given $50,000.
Switching to the new labels required some effort, but the process has gone well, said Ryan Bender, a pharmacist at Hometown Pharmacy in Rio.
The Rio location was one of the first of Hometown Pharmacy’s more than 40 stores to start using the new labels, in June.
The labels, larger than those previously used, and with more white space, seem to be well received by customers, Bender said.
“Nobody has said, ‘How come you changed your labels; I liked the old ones better,’” he said. “Everyone kind of understood intuitively this was a change for the better.”