Improving medication safety during hospital-based transitions of care

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Medication errors are common during transitions of care such as hospital admission and discharge. Problems range from minor discrepancies to actual patient harm. A systematic routine for medication reconciliation can minimize errors, thereby preventing adverse drug events and improving patient safety.


  • Institutional medication reconciliation programs should include taking a best-possible medication history at admission, intervening when patients are at high risk, and involving pharmacy staff when possible.
  • Clinicians can incorporate additional interventions into their workflows to optimize medication safety for hospitalized patients.
  • Reviewing the medication list for errors of omission and commission, patient-specific needs, and “high-alert” drugs further decreases the risk of medication errors.
  • At discharge, patients should receive counseling to ensure understanding of medications and follow-up plans. Hospital physicians should communicate with outpatient providers about medications and rationales for medication changes.



Any time patients enter or leave the hospital, they risk being harmed by errors in their medications.1 Adverse events from medication errors during transitions of care are common but often preventable. One key approach is to systematically review every patient’s medication list on admission and discharge and resolve any discrepancies. These transitions are also an opportunity to address other medication-related problems, such as adherence, drug interactions, and clinical appropriateness.

This article summarizes the types and prevalence of medication problems that occur during hospital-based transitions of care, and suggests strategies to decrease the risk of medication errors, focusing on medication reconciliation and related interventions that clinicians can use at the bedside to improve medication safety.


A medication discrepancy is any variance noted in a patient’s documented medication regimen across different medication lists or sites of care. While some differences reflect intentional and clinically appropriate changes to the regimen, others are unintentional and reflect inaccurate or incomplete information. These unintentional discrepancies are medication errors.

Depending on the clinical circumstances and medications involved, such errors may lead to an adverse drug event (ADE), defined as actual harm or injury resulting from a medication. Sometimes a medication error does not cause harm immediately but could if left uncorrected; this is called a potential ADE.

An important goal during transitions of care is to reduce unintentional medication discrepancies, thereby reducing potential and actual ADEs.


Hospital discharge is a widely recognized transition in which patient harm occurs. As many as 70% of patients may have an unintentional medication discrepancy at hospital discharge, with many of those discrepancies having potential for harm.2 Indeed, during the first few weeks after discharge, 50% of patients have a clinically important medication error,3 and 20% experience an adverse event, most commonly an ADE.4 ADEs are associated with excess health care utilization,5–7 and many are preventable through strategies such as medication reconciliation.5,8

Importantly, more errors arise at hospital admission than at other times.9,10

Errors in medication histories are the most common source of discrepancies, affecting up to two-thirds of admitted patients.11,12 More than one-quarter of hospital prescribing errors can be attributed to incomplete medication histories at the time of admission,13 and nearly three times as many clinically important medication discrepancies are related to history-taking errors on admission rather than reconciliation errors at discharge.9

Most discrepancies occurring at the time of admission have the potential to cause harm, particularly if the errors persist beyond discharge.14 Therefore, taking a complete and accurate medication history on hospital admission is critical to ensuring safe care transitions.


Medication reconciliation is a strategy for reducing medication discrepancies in patients moving across care settings. Simply put, it is the process by which a patient’s medication list is obtained, compared, and clarified across different sites of care.15 It has consistently been shown to decrease medication errors compared with usual care,16 and it is strongly supported by national and international organizations.17–21

In clinical practice, many physicians and institutions have found medication reconciliation difficult to implement, owing to barriers at the level of the patient, provider, and system (Table 1). In response to these challenges, two initiatives have synthesized best practices and offer toolkits that hospitals and clinicians can use: the Medications at Transitions and Clinical Handoffs (MATCH) program22 and the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).23

Lack of resources is a widely acknowledged challenge. Thus, the MARQUIS investigators23 suggested focusing on the admission history, where most errors occur, and applying the most resource-intensive interventions in patients at highest risk of ADEs, ie, those who are elderly, have multiple comorbid conditions, or take numerous medications.16

Although the risk of an ADE increases with the number of medications a patient takes,4 the exact number of drugs that defines high risk has not been well established. Targeting patients who take 10 or more maintenance medications is a reasonable initial approach,24 but institutions should tailor risk stratification to their patient populations and available resources. Patients taking high-risk medications such as anticoagulants and insulin could also be prioritized for review, since these medications are more likely to cause serious patient harm when used without appropriate clinical oversight.7

Using pharmacy staff to perform medication history-taking, reconciliation, and patient counseling has been shown to produce favorable patient outcomes, particularly for higher-risk patients.16,23

The MARQUIS investigators found they could boost the chances of success by sharing stories of patient harm to foster “buy-in” among frontline staff, providing formal training to clinicians on how to take a medication history, and obtaining the support of nursing leaders to champion improvement efforts.23

Additionally, patients should be empowered to maintain an accurate medication list. We address strategies for improving patient engagement and adherence in a later section.


Medication reconciliation is one of several measures necessary to optimize medication safety during transitions of care. It typically includes the following actions:

  • Interview the patient or caregiver to determine the list of medications the patient is currently taking (or supposed to be taking); consult other sources if needed.
  • List medications that are being ordered during the clinical encounter.
  • Compare these two lists, making note of medications that are stopped, changed, or newly prescribed.
  • Resolve any discrepancies.
  • Communicate the reconciled list to the patient, appropriate caregivers, and providers of follow-up care.

At a rudimentary level, medication reconciliation encompasses medication list management along the continuum of care. However, we recommend leveraging medication reconciliation as an opportunity to further enhance medication safety by reviewing the appropriateness of each medication, seizing opportunities to streamline or simplify the regimen, assessing patient and caregiver understanding of medication instructions and potential ADEs, and delivering appropriate counseling to enhance medication use. Table 2 outlines our framework for medication management during hospital-based transitions.

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