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Patient Safety Impact and Burden:
Medication Reconciliation in Care Transitions Between Hospitals and Nursing Homes

Nurse giving older woman glass of water

Current medication reconciliation processes in care transitions from hospitals to nursing homes pose risks for patient safety and result in significant time diverted away from patient care. Approximately half of hospital related medication errors and 20 percent of adverse drug events are due to poor communication at transitions. A lack of consistent protocols for medication reconciliation across these care settings has been identified as a key issue.

The new Stratis Health white paper "Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes" analyzes the resources diverted from care in today’s current transition processes and offers three actions to facilitate improvement.

Patient safety risk and inefficiency

A lack of understanding about workflows between organizations results in inefficient care transitions that can put patients at risk. Wasted effort for health care professionals to correct a medication discrepancy is estimated at 4.3 hours, while following up on a missing indications and/or diagnosis is estimated at 9.75 hours because of the uncertainty of who to contact for follow up.

Medication reconciliation acts as a safeguard for patients by comparing a patient’s current medication regimen against the physician’s admission, transfer, and discharge orders to identify discrepancies. It includes a medication evaluation which aims to prevent potential medicationrelated problems, such as issues that result from inappropriate use of antipsychotics for people with dementia.

4.3 hours

to correct a medication discrepancy

9.75 hours

to follow up on a missing indications and/or diagnosis

How to improve medication management in care transitions

Stratis Health recommends three actions for improving medication management in transitions of care by improving workflow in health care settings. The recommendations are made from a quality improvement perspective, with the intent to give guidance to and support action by hospitals, nursing homes, and pharmacists. These recommendations also can inform policy and regulatory considerations and action.

  1. Implement interventions that assure indications and diagnoses are documented for all prescribed medications.
  2. Increase pharmacy’s role in medication reconciliation in transitions of care.
  3. Implement an interdisciplinary approach to medication reconciliation that occurs before or during the care transition that includes hospital, nursing home, and pharmacy staff.

The white paper outlines a workflow for successful medication reconciliation in care transitions.

Download the white paper (13-page PDF).