once the medication is prescribed, how well do people consistently adhere to the instructions? There are drug-labeling issues. What can pharmaceutical companies do in labeling and information? An opportunity map can be created for each participant.

Since this is a health literacy meeting, what contribution can health literacy make in partnership with others? Who should be at the table?

Ruth Parker expressed concern about going one drug at a time, versus a more cross-cutting approach. The data exist about the top three drugs, but it might not get the process far enough. She advocated looking at all levels, all the points—labeling, dispensing containers, communication, follow-up—but from a patient-centered view. What is going to make the consumer most likely able to do what he or she needs to do safely and effectively?

Wolf said perhaps singling out the three drugs with the highest rates of adverse drug reactions could be a first step for dealing with specific things in the health care system—things such as pulling someone off a medication or not prescribing it when it is not called for—quality control issues that are not in the patient’s hands, but rather the hands of the systems or providers. It is important to remember that it is unlikely the patient is taking only one medication.

Budnitz weighed in on the debate over targeting high-risk medications, or situations that data show cause lots of harm, versus a more systematic change. The challenge is finding winnable battles, places where it is possible to demonstrate effect. There is the concern about building interventions in silos.

The PROTECT Initiative, which focused on medication overdoses in children, is an example of what can be done. It began with over-the-counter (OTC) medications because that was the opportunity to get stakeholders together to implement some change. The hope is those changes will be transferred to prescription medications in the future, and to how volume measures go on all liquid medications. In other words, there are some lessons that can be applied to other medications. There is a way to think about the big picture, but start somewhere with a concrete effort. If we try to start fixing everything at once, there are a lot of ways to go wrong.

Where can this group carry out some concrete, high-impact interventions that can be a model for a system-wide effort later? The FDA’s Weiss liked the idea of doing both: go vertical and horizontal. She noted that Sharfstein said pick low-hanging fruit, test the idea and see how it works, then show tangible results and apply elsewhere. And do not forget the people who will be newly insured under health care reform, who haven’t been plugged into the health care system. How will they be reached?

Yin pointed out that everyone is talking about a systematic approach

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