How to Prevent Medication Errors During Care Transitions and Discharge

Every year, medication errors during care transitions send hundreds of thousands of patients back to the hospital - not because their condition got worse, but because the wrong pill was given, a duplicate was prescribed, or a critical drug was simply missed. This isn’t rare. It’s routine. And it’s preventable.

When a patient moves from hospital to home, from ICU to ward, or from one doctor’s office to another, their medication list should be double-checked, rewritten, and confirmed. But too often, it’s not. The result? A 60% spike in errors during these handoffs, according to the Agency for Healthcare Research and Quality. That’s six in every ten patients at risk of harm simply because no one took the time to get the list right.

Why Medication Reconciliation Is Non-Negotiable

Medication reconciliation isn’t paperwork. It’s a safety net. It’s the process of making sure every medication a patient is taking - from blood pressure pills to herbal supplements - is accurately recorded, compared, and confirmed at every point of care change. This includes admission, transfer between units, and especially discharge.

The Joint Commission has required this since 2005. The World Health Organization made it a global priority in 2017. And yet, only 42% of U.S. hospitals do it well, according to Dr. Robert Wachter. Why? Because it’s messy. Patients forget names. Family members give conflicting info. EHR systems don’t talk to each other. Community pharmacies don’t share data electronically with hospitals. Only 37% of U.S. hospitals can automatically pull in a patient’s community pharmacy history.

Here’s what happens when you skip this step: A patient gets discharged on warfarin, but the discharge summary doesn’t mention the aspirin they were taking at home. Two weeks later, they bleed internally. Or a patient is switched from insulin glargine to insulin lispro during hospitalization, but the discharge script says glargine again. Blood sugar crashes. Emergency room visit. Again.

The Four Steps That Actually Work

There’s no magic tool. No single app. Just four clear, repeatable steps - and doing them right every time.

1. Get the real list. Don’t trust the chart. Don’t rely on what the patient says they take. Talk to them. Talk to their caregiver. Call their pharmacy. Ask: “What are you taking right now, and why?” Include over-the-counter meds, vitamins, and supplements. One study found 83% of patients were taking at least one unreported supplement.
2. Build the new list. Based on their hospital stay, what meds are they starting, stopping, or changing? Write it down clearly. Use plain language. No abbreviations. No “QD” - write “once daily.”
3. Compare the two. Side by side. Look for duplicates, omissions, dose changes, interactions. Is the patient getting two blood thinners? Is a kidney drug still on the list after their creatinine jumped? Flag everything.
4. Decide and document. Who’s responsible for the final list? The nurse? The pharmacist? The doctor? It has to be clear. Then, give the patient a printed copy. Read it to them. Ask them to repeat it back. If they can’t, you haven’t finished.

That’s it. No fancy tech required. Just discipline.

Technology Helps - But Only If Used Right

Computerized Physician Order Entry (CPOE), barcode scanning, and EHR systems have cut medication errors by nearly half in hospitals. But here’s the catch: when hospitals first roll out new EHRs, medication discrepancies often go up by 18%. Why? Because staff are overwhelmed. They click faster than they think. They copy-paste old lists. They assume the system got it right.

The real game-changer? The AHRQ’s MATCH toolkit. It doesn’t just give you software. It gives you workflows. It tells you who does what, when, and how long it should take. Hospitals that followed all 159 recommendations saw a 63% drop in errors. Those relying only on EHRs? Just 41%.

Pharmacists make the biggest difference. Facilities with dedicated transition pharmacists saw 53% fewer adverse drug events. One pharmacist in Chicago caught a duplicate anticoagulant order that would’ve caused a major bleed. “That’s why I do this work,” she said.

But tech has limits. In 2024, 68% of pharmacists still had to call community pharmacies manually to get accurate medication histories. That’s not efficiency. That’s firefighting.

Who’s Responsible? The Role Problem

Everyone thinks someone else is handling it. Nurses assume the doctor wrote it down. Doctors assume the pharmacist checked it. Pharmacists assume the nurse confirmed it with the patient.

That’s the problem. No one owns it.

Research shows that when roles are clearly defined - for example, the pharmacist leads reconciliation at admission, the nurse verifies at discharge, and the physician signs off - harmful discrepancies drop by 27%. The MARQUIS study found that training staff without assigning clear roles actually increased errors by 15%.

At discharge, the person who hands the patient the script should also be the one who explains it. Not the resident who’s rushing to leave. Not the scribe who typed it. The provider who knows the patient’s history, goals, and fears.

The Patient Isn’t Just a Recipient - They’re Part of the Team

Seventy-two percent of patients don’t understand why their medication list matters during transitions. That’s not their fault. It’s our failure.

But when patients are involved - when they’re asked to bring a bag of their meds to the hospital, when they’re given a printed list in plain language, when they’re asked, “Can you tell me what each of these pills is for?” - 85% feel more confident. And confidence reduces errors.

Some hospitals now give patients a “Medication Passport” - a small card they carry with them. It lists all current meds, doses, allergies, and the name/phone of their primary pharmacist. Simple. Portable. Powerful.

Patients aren’t the problem. They’re the solution.

What’s Holding You Back?

Time. Staffing. Resistance.

Doctors say reconciliation adds 12 to 15 minutes per patient. Nurses say they’re already overwhelmed. Administrators say it’s too expensive.

But here’s the cost of doing nothing: 800,000 preventable medication errors in the U.S. each year. $2.1 billion in avoidable hospital costs. Lives lost. Families shattered.

Implementation takes 6 to 9 months. It’s not quick. But it’s not impossible. Start small. Pick one unit. Train one team. Assign one pharmacist. Measure the difference. Then scale.

One hospital in Ohio cut readmissions by 38% in 30 days just by having pharmacists review every discharge list. Another in California reduced medication discrepancies by 57% by having nurses call the patient’s pharmacy before discharge.

What’s Changing in 2025?

The National Patient Safety Goals for 2025 are tightening the rules. Starting January 2025, hospitals must verify high-risk medications - like insulin, warfarin, and opioids - against at least two independent sources. No more relying on one chart. No more “I think they were on this.”

WHO’s Phase 2 of “Medication Without Harm” is targeting transitions specifically. The goal: reduce harm by 30% in high-risk scenarios by 2027.

New tools are emerging. MedWise Transition, an AI-powered reconciliation tool cleared by the FDA in August 2024, reduced discrepancies by 41% in a pilot across 12 hospitals. It doesn’t replace people - it helps them work faster and smarter.

And the money’s coming. The global medication safety tech market hit $3.27 billion in 2023 and is growing at 14.3% a year. CMS is now tying payments to safety performance. Hospitals with poor reconciliation rates could lose 0.5% to 1.5% of their reimbursements.

Where to Start Today

You don’t need a new system. You don’t need a budget increase. You need to do three things:

1. Assign ownership. Who is responsible for reconciliation at admission? At transfer? At discharge? Write it down. Post it.
2. Train your team. Not a 30-minute PowerPoint. A 2-hour session where staff practice taking a real medication history from a colleague using a mock patient scenario.
3. Give patients a list. Print it. Read it. Ask them to repeat it. Make sure they know what each pill is for and why they’re taking it.

That’s it. No apps. No fancy software. Just attention. Consistency. And care.

Medication errors during transitions aren’t inevitable. They’re a choice. And the choice to fix them starts with one person deciding: ‘I won’t let this happen on my watch.’”