The inability to perform self-care is another barrier to medication management when the impairment is high, when individuals are too sick to care for themselves, or when they are rendered unconscious. In such cases, individuals must rely completely on providers and other caregivers (e.g., family members, friends, surrogates) for medication management, safety, and error prevention. In these circumstances, informal caregivers require adequate training, education, and emotional support to carry out this role, whether for a short period, such as when a patient is postoperative, or for chronic conditions that require long-term care. Such caregivers can experience a significant burden that affects their quality of life and mental and physical health (McCullagh et al., 2005; Schrag et al., 2005; Vanderwerker et al., 2005), which in turn can result in medication errors.

It must be stressed that any policy or provider action that prevents a patient from having a designated surrogate present whenever the patient is receiving medication can be considered a barrier to safe and effective medication management. Given the amount of evidence for the occurrence of medication errors in hospitals, surrogates should be encouraged to question any professional about medications, routes of administration, and doses, and should be partners in reporting side effects patients may not be able to report themselves.

Another practical barrier to medication self-management can be the difficulty of opening a pill bottle or container, especially if an individual’s manual dexterity has been compromised by his or her condition (e.g., arthritis, broken arm, disability). Such individuals may give up trying to open the bottle and simply not take the medicine.

Undesirable drug side effects (expected or not) distress patients, add to the burden of their illness, and increase the costs of care (Barsky et al., 2002). They may result in nonadherence or discontinuation of an otherwise appropriate therapy, or they may increase the complexity of the regimen as drug(s) are added to treat the side effects. Polypharmacy contributes significantly to the likelihood of adverse drug reactions and drug–drug interactions. Difficulties with side effects are exacerbated in those that have impaired renal and hepatic function as a result of either age (e.g., seniors) or illness (e.g., HIV) (Cohen, 2000; Murray and Kroenke, 2001). Drug toxicity can manifest as a decline in functional status (e.g., problems in performing activities of daily living, confusion, drowsiness, and depression) or a more pronounced acute or long-term reaction (e.g., vomiting, heart arrhythmia) (LeSage, 1991).

The inability to pay for medications (or for health care in general) is one of the most frequently cited practical barriers to medication adherence, as well as to overall self-management of health conditions (Safran et al., 2005; Piette et al., 2006). To minimize out-of-pocket costs for drugs, individuals who are uninsured or underinsured may not fill a prescriptions at



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