Patient Safety Impact and Burden:
Medication Reconciliation in Care Transitions Between Hospitals and Nursing Homes
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
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 hoursto correct a medication discrepancy
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
- Implement interventions that assure indications and diagnoses are documented for all prescribed medications.
- Increase pharmacy’s role in medication reconciliation in transitions of care.
- 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
Download the white paper (13-page PDF).