Ineffective Communication between Patients and Health Workers is one of the Main Reasons for Increasing Medication Errors

Ineffective Communication between Patients and Health Workers is one of the Main Reasons for Increasing Medication Errors

I was still a First-year intern in Family medicine when a patient entered the emergency department at a hospital in Catalonia in Spain, in one of my night shifts. He was in the fifth decade of his life and was feeling so bad: very low blood pressure, dizziness, headache and severe sweating. I went with my supervisor consultant doctor to inspect him. We requested him to expose his chest for inspection, and there was waiting for us a surprise!

Two days before the visit to the emergency department, the patient had been discharged from the Department of Cardiology after been admitted for 2 weeks for suffering a heart attack. Diagnosed with acute coronary syndrome, he had undergone various investigations and treatments, then he was discharged home with a full medical report on diagnosis, treatment and timing of follow-up with the specialist doctor.

Returning to the emergency scene, 14 patches of nitroglycerin were on the patient's chest, knowing that the prescribed dose is only one patch normally! After the emergency medical intervention was done, I asked the patient when he was resting in his box about why he put all these patches, which in turn led to the situation that he was on when he came to the emergency department. The patient replied:

In the medical report it was written:

Patch on the chest to be put from 9h to 20h.

I got confused how many I should put, and then decided to calculate the medium and put 14 patches!

It is obvious that the sentence in the report was not clear enough for that patient and for many others to think that the 9h is 9 am and the 20h is 8 pm, and that the patch should be placed from 9 am till 8 pm, time when it should be removed.

Ineffective communication between patients and healthcare professionals is one of the main causes of errors in medication. There are two types of medium or ways of communication: mediated and non-mediated forms of communication. The communication is ‘non-mediated’ when the health personnel and patient are together in one another’s presence. However, the communication is mediated when it takes place via telephone, e-mail, letter, or computerized records.

 One of the studies found that when initiating new medications, health professionals usually fail to communicate effective medication use, which can contribute to poor understandings of medication directions or use, thereby leading to poor compliance with the medication.  

On the other hand, healthcare professionals tend to use technical language in the workplace because they consider that the tone of communication should always be professional, but this does not guarantee proper communication with patients. The use of symbolic abbreviations might be one of the most important causes of errors in medication. It can create some ambiguity and anxiety to patients. According to the one study done in 2017, nurses, doctors, and pharmacists failed to use simple language to communicate with the patients, almost 19.0% of the health practitioners examined in the study did not frequently use simple language and avoid medical terms during communication with patients. When medical practitioners speak a common “medical language”, much can be lost in the transfer of information to the patients.

How to Avoid Errors in Medication:

  1. Teamwork and team communication in critical and life-saving situations.

  2. Reassure that the language used in communicating with the patient is appropriate, simple, and clear. Technical expressions should not be used, and only well-known abbreviations should be included to avoid misinterpretations.

  3. Both verbal and written communication occur together in a favorable quiet setting, where doubts can be assessed and clarified.

  4. If possible, the use of a visual aid.

 Patients need knowledge and support to be able and motivated to undergo pharmacotherapy. Health practitioners must therefore feel responsible and create an environment in which quality health care counseling is routinely provided. To promote safe and effective practice in hospitals and avoid medication errors, doctors must commit to teamwork and effective communication with patients.

Nowadays, it is not only a need, but rather a requirement for a quality healthcare to design strategies such as effective communication and teamwork among healthcare professionals to optimize healthcare, avoid errors in medication, and thus improve patients’ outcomes.



Shitu, Z., Hassan, I., Aung, M. M. T., Tuan Kamaruzaman, T. H., & Musa, R. M. (2018). Avoiding medication errors through effective communication in healthcare environment. Movement, Health & Exercise, 7(1), 115-128.