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Reporting a Medication Error

Lost in Translation

Published April 15, 2024

Many pharmacies are required (by their state licensing board) to provide people who do not speak English information about their medicine in their preferred language. This includes directions on how to take the medicine. These directions can be printed on the pharmacy label or on a separate sheet of paper. We also recommend that pharmacists provide verbal instructions by using a trained interpreter or through a language line service. However, we have received reports that providing information in non-English languages is not easy and has led to errors.

We heard from a pharmacist who said their computer system incorrectly translated medicine directions into Spanish. The prescription was for liraglutide (Victoza) pens with instructions to “inject once daily as directed.” However, the Spanish instructions that were printed on the label, “Inyectar 3 veces al dia. Usar todos los dias segun lo indicado,” translated to “inject the medicine three times a day and to use every day as directed.” Liraglutide is intended for daily administration, not three times a day. The prescription with the incorrect instructions was dispensed multiple times before it was discovered. We do not know if the person was harmed.

Here’s what you can do: If you, a family member, or friend do not speak English as your primary language, let your healthcare provider know. Ask for any medical and medicine information in your preferred language. When picking up a prescription, ask to speak to the pharmacist. If possible, use an interpreter or language line to learn how to take your medicine correctly. Repeat back to the pharmacist how you plan to take your medicine and have them confirm this is correct. Ask your pharmacist for any printed material in your preferred language.

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