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doi:10.3928/24748307-20190107-01 Given the prevalence of medication nonadherence (Sabaté, 2003), clinicians and public health researchers are compelled to design, implement, evaluate, and iterate strategies to improve fidelity to medication regimens. Although barriers to medication adherence range from the individual to the structural, addressing the ambiguity, technicality, and variability of traditional instructions are among the most actionable barriers to comprehension and adherence. In November 2015, the governing body of Zuckerberg San Francisco General Hospital (ZSFG) decided to implement the Universal Medication Schedule (UMS), evidencebased, plain-language medication instructions. The Ambulatory Safety CEnter for iNnovaTion, funded by a National Institutes of Health grant (P30HS023558-01), led this effort. A prior report describes the implementation outcomes at the four sites (Khoong et al., 2018). Despite the UMS’s proven ability to promote accurate recall and comprehension among populations at greatest risk of adverse drug events and nonadherence (Bailey, Agarwal, Sleath, Gumusoglu, & Wolf, 2011; Bailey, Sarkar, Chen, Schillinger, & Wolf, 2012) barriers heretofore unknown and unanticipated compromised UMS implementation at ZSFG’s outpatient pharmacy. Given the higher prevalence of barriers to medication comprehension in these settings, such as limited health literacy and/or English proficiency (Bailey et al., 2011; Masland, Kang, & Ma, 2011; Tache, Sonnichsen, & Ashcroft, 2011; Zhan et al., 2005), our inability to successfully implement the UMS in the safety-net settings requires further focused attention. Below we elaborate on tensions described in our short report (Cherian et al., 2018).

Standardization in Diverse Populations: Implementation of Evidence-Based Practices in a Safety-Net Setting