Getting the Right Medications Before and After Hospital Discharge

According to the Institute of Medicine’s Preventing Medication Errors report, the average hospitalized patient encounters at least one medication error per day. One in five errors harms the patient. More than 40 percent of medication errors arise during care transitions (admissions, transfers, and discharges from one setting to another) when various possible medication lists are not brought together in a process called reconciliation. Having good medication reconciliation processes in place and collecting accurate medication history from the patient or caregiver turns out to be essential to good care. (1)

Medication reconciliation is the process of comparing a patient’s current medication orders to all of the medications that anyone believes that the patient takes. This process aims to stop omissions, duplications, dosing errors, allergic reactions, contraindicated medications, and drug interactions. The process needs to be repeated at every transition of care, especially when the patient has new medications or someone is rewriting what they believe are the existing orders. 

Research concerning medication reconciliation and adverse drug events has focused on the hospital setting and transition to home. The usual transition appears to have at least one error. Up to 67 percent of inpatients have at least one error in their prescription medication history at the time of admission (2) and about 20 percent of patients discharged from hospital to home will have a clinically significant adverse drug event (3) some patients may be rehospitalized or even die from such mistakes. 

Medication reconciliation poses substantial difficulties and is not easy to do well. The clinician involved must have detailed knowledge of the patient's prior medication history and hospital course, as well as clinical judgment to determine optimal medications and to negotiate honestly with patient and caregivers as to a workable and acceptable plan. The medically optimal plan may be unaffordable, might entail unacceptable side effects, or might just be too complicated for the patient and family to follow. 

Consider how complicated it is to get an accurate medication history on admission to the hospital. Relying on reports from the patient or family often encounters deficits in knowing precise names, doses and schedules. Information may come only in the form of “I take a little yellow pill for my heart every morning.”  Reports from electronic records, when they exist, often are incomplete because not every clinician is on the record string—and often are misleading because the patient may not fill or take the medication prescribed. Of course, patients also are often taking herbs, medications borrowed from a family member, and quite outdated prescriptions—and they may be reticent to admit that they have been coping in these ways.

The patient and/or caregivers must be capable of self-management after discharge, and that requires teaching, teach-back and often further negotiation to address barriers to implementing the medication plan. Having patients and families take an active role in managing medications turns out to be a very good strategy. They are the only parties who are always there—and, with some help, they can at least know what the current medication schedule is. Many people with complicated regimens or hazardous medications now keep their list on a computer, though keeping it up to date using a simple handwritten table also works.

The trick is to have the energy and authority to insist upon it being updated before the patient leaves an encounter with a prescribing clinician. This can take some fortitude—the patient may have to stop the rapidly disappearing doctor and say that he needs another couple of minutes to be sure he understands the medications, or the family may have to refuse to leave the office or hospital until an appropriate clinician answers their questions. Being so proactive about one’s own health care is quite contrary to the culture of the hospital, which often seems designed to reduce patients and families to passive acceptance.

Of course, an up-to-date electronic record can also complement the efforts of the patient, family and clinicians. A good record can be shared with patient and family, who can enter corrections and questions. The record can also do automatic checks on compatibility, allergies, duplications, inadvertent discontinuation, unusual doses, or routes or schedules, and other supportive checks. Much of the better health that people with serious illnesses now experience arises from the multitude of truly effective medications now available. However, the array of medications often exceeds our ability to manage them well. 

Electronic records, patient/family activation, and clinician attention should be able to curtail this major source of harm. The Partnership for Patients is investing substantially in improvement activities that will address this problem, and the meaningful use requirements ( ) and financial incentives for better electronic record systems ( ) could “turn the corner” on this course of error and harm. But until that good day comes, the patient and family may be the best defenders of their interests and health care.  


1. The Joint Commission. (2011). Hospitals’National Patient Safety Goals. Retrieved from
2. Pippins, J. R., Gandhi, T., Hamann, C., Ndumele, C., Labonville, S. A., Diedrichsen, . . . Schnipper, J. L. (2008). Classifying and predicting errors of inpatient mediation reconciliation. Journal of General Internal Medicine, 23(9), 1414-1422. 
3. Coleman, E. A., Smith, J. D., Raha, D., & Min, S. (2005, September 15). Posthospital medication discrepancies and contributing factors. ARCH Internal Medicine, 265, 1842-1947.



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