AJN, American Journal of Nursing:
The dangerous convergence of small typefaces, dim lighting, aging nurses.
Janeen Jones is a staff nurse on the postanesthesia care unit at MetroHealth Medical Center, Cleveland, OH. Contact author: firstname.lastname@example.org. The author has disclosed no potential conflicts of interest, financial or otherwise.
We often read about potential causes of medication errors, such as drug names that are overly similar or misplaced decimal points in iv drug administration. But sometimes we overlook more obvious dangers. My experience as a nurse suggests that our patients are increasingly at risk for medication errors because of the convergence of three factors: difficult to read medication labels, the increasing age of the nursing population, and poorly lit work environments. This combination can lead to disaster.
I initially believed the tiny print on medication labels was only a problem for older nurses with aging eyes like me. (Presbyopia, the decreased ability of the eye to focus on near objects, commonly starts to appear around the age of 40.) Working as a clinical instructor to second-year nursing students, I found older nurses are not the only ones having trouble with fine print. One of my students, while carefully reviewing each of her patient's medications with me, was ready to administer an extended-release medication, crushed, through her patient's feeding tube. “Extended release” was printed below the name of the medication in barely readable 1-mm high letters. She hadn't seen it. Had she crushed and administered the drug, 24 hours worth of medication would have been released immediately, rather than slowly over a whole day. Her patient might not have survived that dose.
I decided to informally survey bedside nurses, nurse educators, pharmacists, and respiratory therapists to find out who else was having trouble reading drug labels. The results from the online survey are frightening. Of the nearly 100 responses I received, almost all of the nurses reported having difficulty reading the small text on medication labels. Almost half of the respondents were aware of a near miss or an actual error that could be at least partly attributed to difficulty reading the small print on medication labels and packaging. Virtually all survey respondents said that improving readability would reduce potential medication errors. The results convinced me I am not alone in my concern.
If the fine print is getting you down, it's not surprising. Unit dose package sizes that I work with on a daily basis average around 3.5 cm × 2 cm, with some print as small as 1 mm in height (about the thickness of a dime). The U.S. Food and Drug Administration (FDA) recommends the use of more readable fonts, as well as a minimum point size for labels and adequate white space between words; however, it also requires that labels include drug name, dose, lot number, manufacturer, expiration date, special requirements for handling, and important descriptors such as SR, XL, and EC. Additional items drug manufacturers may choose to include are the manufacturer's address, National Drug Code number, generic name, and bar code. That's a lot of information to squeeze into a tiny space. (FDA policy states that “a firm may not claim an exemption on the basis that the label is too small to accommodate all mandatory information if all available space is not utilized or the label size can readily be made larger.”)
According to the 2008 National Sample Survey of Registered Nurses, the median age of a nurse in the United States is over 45, and nurses over 50 will soon make up nearly a quarter of the workforce. Presbyopia is an almost universal result of eye aging, so the majority of working nurses are experiencing it. Nurses care for patients 24 hours a day. Work environments can get pretty dark at 2 am; poor lighting compounds the problem, making the fine print even more difficult to read.
Small print is not just a problem for nurses my age but for everyone. Patients’ lives depend on accurate and safe medication administration. What can we do to avoid tragedy? Small print is a modifiable risk factor and needs to be addressed to prevent medical errors. So read carefully, and for now, wear your cheaters and turn the bright lights on!