How bilingual labels can lead to safer medications

A Q&A with Ghalib Khan, founder of Written Medicines, software for creating bilingual medication labels, for World Patient Safety Day on 17 September.

How did you recognise the need for bilingual labels?

I used to work in a community pharmacy in central London, in a very diverse community where a good 40% of the area is black and ethnic minority and every third patient that came in has some form of language and communication barrier.

We also get a lot of tourists from Baker Street and Marble Arch coming through who have forgotten their medication or run out of medication, as well as private patients from the HCA Wellington, which sees a lot of international patients, predominantly from the Middle East.

What inspired me to create Written Medicine was speaking to a patient whose spoken English was quite good. And then I saw her write on the medication box in her own language, in Arabic, how to take the medication. This is quite usual – we see patients writing it if it’s to be taken with food, or after food, or what the medication is for if they're on multiple medications and hence why we created a solution. We hire bilingual staff to accommodate our patients, but we can’t cater for everyone.

We created a pilot in Arabic, and later added five languages.

Our first customer was Ealing Hospital and then, as they were absorbed into London North West Healthcare, which is a one of the largest trust in London, we went into the Norfolk Park Central Middlesex as well. Currently we're in Bedfordshire Hospitals NHS Trust and East London Foundation trust. We're going back in for another pilot with Barts soon as well.

Why are bilingual labels important for patient safety?

In 2017, we got funding from Health Education England and partnered with Portsmouth University to run a study that was published in a peer reviewed journal in 2019. We did this with 12 community pharmacies and 156 patients across London who completed a baseline and a follow up questionnaire.

We found that 58% of the patients, before we made an intervention, said that they were confident in taking the medication in English only. But when we made an intervention [using the bilingual labels], 62% discovered that they had been making mistakes – like an increased or decreased dose, or not reading the BNF warnings like not drinking alcohol with medication.

I’ll give you an example from a secondary care environment. Parents collected medicine for their child from the hospital. They went home and because they had forgotten what the instructions were, the child took an overdose. So that means the patient ends up coming back into the system. Luckily, nothing untoward happened to the child. However, if you just imagine what the potential of that could have been, it's massive.

What are the issues with reading a label in a second language?

There's the problem of 'false friends' (same spelling, but different meaning). For example, if the label say ‘take one tablet once daily’, ‘once’ is the same spelling as 11 in Spanish.

Why else are bilingual labels important?

Sometimes patients don't want their confidentiality being affected. However, if they can't speak and read and write English, and that means they have to take their friends, family and children into consultations; that means forgoing confidentiality.

In our study, with the bilingual labels 98% of patients were able to read the content, and understanding improved from 30% to nearly 90%. Adherence improved to 82% and independence improved from 23% to 75%.

What about other communication difficulties?

We’re also looking at providing accessible medication content via pictograms, working with MHRA and the GPhC as well as NHS England's learning disabilities team and patient involvement teams.

How can pharmacists be confident that the translation is accurate?

Our languages go through a very intensive four-step verification process – multiple people will have looked at them, including patients and the public.

The BMJ states that Google Translate has an error rate of 90% from European to non-European languages. It's been advised not to use Google Translate, even though pharmacists do heavily depend on it in in circumstances like mine.

The biggest errors [with Google Translate] are where you have one word but multiple meanings. ‘Your husband's gone through a cardiac arrest’, in South Asian languages, could translate to ‘your husband's heart has been in prison’, because the word arrest has multiple uses.

We've got a full clinical safety case and hazard log. This is something that's mandatory from NHS Digital – all IT systems have to provide that in healthcare.

Our labels also meet clinical standards: the drug name, how it’s displayed; directions of use - is it clear, is it safe and full instructions? We meet all of those clinical safety standards and we meet some of the legal information as well, so for example what language it is displayed on the label.

How can community pharmacists use this system?

We would work with the local ICSs to get this paid for, or if a community pharmacy would like to use it, they can access our software directly from us, we can give them a login details and we've got various different plans that we can get them on.

Aside from patient safety, what’s the advantage of offering bilingual services?

In our study, 80% of patients wanted this as a regular service, and 66% said it would influence their choice of pharmacy.

Our translations cover, I’d say, 99.9% of directions of use.

If I'm a patient who has got language barriers and that language need is being met by an independent pharmacy who speaks their language, and there's a pharmacy right next to it that belongs to one of the major chains which doesn’t meet its language needs, then that patient’s going to go and use the pharmacy where the language is being met.