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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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The Many Roads to Medication Adherence

Posted By Administration, Tuesday, November 15, 2016

Medication adherence is a major challenge, particularly in outpatient settings.
We need a multipronged approach to improvement.

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

Last month in this column I wrote about the importance of addressing patient safety across the continuum of care. As an example of how challenging this is, let’s take a look at one aspect of outpatient safety: medication adherence.

Medication adherence problems are not simply a matter of patients accidentally missing a dose. Primary nonadherence occurs when patients do not take the step of filling or picking up a prescription. But nonadherence also includes taking a lower or higher dose than prescribed; stopping a prescription early; taking an old medication for a new problem without consulting a doctor; taking medication prescribed for someone else; and forgetting whether a medication has been taken.

These are major problems in the ambulatory arena, where patients or their family members serve the vital role of administering medication.

Most health professionals recognize the challenges involved when patients do not take medications as directed—or at all—whether intentionally or unintentionally. In one study of 195,000 newly prescribed e-prescriptions, only 72% were filled. Nonadherence was common for medications for chronic conditions such as hypertension, diabetes, and hyperlipidemia.


When medication is not taken as prescribed, health problems may worsen, requiring more intervention. Nonadherence not only poses risks to patients’ health, it also costs our health care system an estimated $100 billion annually in avoidable hospitalizations.

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Medication Adherence in Practice

The issue of not taking medications—and how to improve it—is linked to several major themes in patient safety:

  1. Patient and family engagement. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, most definitions of patient engagement include ideas such as partnership, communication, information exchange, and respect. Health care practitioners can help improve adherence by making sure patients understand why the medication has been prescribed and how to take it properly, and by answering questions and addressing concerns.

  2. Health literacy. More than one-third of US adults have below basic or basic health literacy skills. Health literacy involves the ability to not only read and follow instructions, but also work with numbers and understand what to do if something goes wrong, if a dose is missed, or if an adverse event occurs.

  3. Transitions in care. Patients recently discharged face challenges in adhering to medication regimens that may have changed since they entered the hospital. In one study, 29% of patients were not taking a medication on their discharge list, were taking a different does or frequency, or taking an additional medication.

There is no easy solution and, in fact, a multipronged approach is likely needed to improve medication adherence. Zullig and colleagues note that greater research and evaluation of strategies, similar to the drug development process, is needed to encourage adherence. Furthermore, they note that the success of each strategy may differ between patient populations and settings, and that efforts are needed for wide dissemination and adoption of proven interventions.


Other interventions are currently being tested:

  • Mobilizing pharmacists to answer patients’ questions and be sure they know how to take medication properly.
  • Encouraging the use of patient portals by patients to become familiar with their medications, order refills, or ask questions.
  • Exploring pill monitoring technology, such as electronic pill caps and “smart” blister packaging.
  • Using innovative options such as electronic monitors (for example, biometric monitors or activity monitors) and mobile health strategies (such as text messaging and smartphone apps) to alert health practitioners about medication adherence and remind patients to take their medication. One of the eight recommendations of the NPSF Free from Harm report is to ensure that technology is safe and optimized to improve patient safety. There is much promise in the drive to use technology to improve medication adherence.

We still have work to do to determine the best strategies to improve this area of patient safety, and we need to match interventions to each patient’s individual needs. But we are at a point where innovations in technology, coupled with increased education among providers about the issue, may converge to help improve medication adherence across the continuum of care.

What strategies do you think will encourage medication adherence? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  ambulatory  medication  patient engagement 

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