How to Prevent Medication Errors During Care Transitions and Discharge

Every year, hundreds of thousands of patients in the U.S. and Australia are harmed because their medication list gets lost, mixed up, or forgotten when they move from hospital to home, or from one doctor to another. These aren’t rare mistakes-they’re predictable, preventable, and happening far too often. In fact, medication reconciliation is the single most effective way to stop these errors before they hurt someone. Yet, only about 42% of hospitals do it well. If you’re a patient, a caregiver, or a healthcare worker, you need to know how this works-and how to make it work for you.

What Is Medication Reconciliation, and Why Does It Matter?

Medication reconciliation isn’t just checking a list. It’s a full process: getting the most accurate picture of what a patient is really taking, comparing it to what the care team thinks they’re taking, and fixing any mismatches. This happens at every handoff-admission, transfer between units, and especially discharge.

Think about it: a 72-year-old woman with high blood pressure, diabetes, and atrial fibrillation comes into the hospital after falling. She’s on warfarin, metformin, lisinopril, and a daily aspirin. But when the nurse asks her what she takes, she says, “I take my pills in the morning.” She doesn’t remember names or doses. The doctor orders a new blood thinner because they don’t know she’s already on warfarin. That’s how a bleeding emergency starts.

The Joint Commission has required medication reconciliation since 2005. The World Health Organization made it a top priority in their Medication Without Harm campaign. And the data backs it up: hospitals that do this right see 57% fewer medication errors after discharge and 38% fewer readmissions within 30 days.

The Four Steps That Actually Work

There’s no magic tool or app that fixes this alone. It’s a process with four non-negotiable steps:

1. Get the best possible medication history-not from memory, not from a printout from last year. Talk to the patient, their family, their pharmacist, their GP. Call the community pharmacy. Check the state prescription drug monitoring program if available.
2. Create the list of medications to be prescribed-this is what the hospital team plans to give during the stay and at discharge. Don’t assume. Write it down.
3. Compare the two lists-side by side. Look for omissions, duplications, wrong doses, drug interactions. Is the patient still on a statin they stopped six months ago? Is there a new blood pressure pill that clashes with their kidney meds?
4. Make clinical decisions and communicate them-if a medication is stopped, why? If a new one is added, explain it clearly. Document everything. Hand it off in writing and verbally.

The AHRQ’s MATCH toolkit gives detailed guidance on each step. It’s not theory-it’s a step-by-step playbook used by top-performing hospitals. And it works. Facilities that follow all 159 recommendations reduce medication errors by 63%.

Technology Helps-But Only If It’s Done Right

EHRs, CPOE systems, barcode scanning-they sound like the answer. And in some ways, they are. Studies show these tools can cut medication errors by nearly half in acute settings. But here’s the catch: when hospitals roll out new EHRs without training or workflow changes, medication discrepancies go up by 18% in the first six months.

Why? Because the system doesn’t ask the right questions. It auto-populates old meds. It doesn’t flag a duplicate dose of metformin because the patient’s primary care doctor changed the dose two weeks ago. It doesn’t know that the patient stopped taking their diuretic because they couldn’t afford it.

Barcodes help with administration, but they don’t fix the list. AI tools like MedWise Transition, cleared by the FDA in August 2024, are promising-they reduced discrepancies by 41% in a 12-hospital pilot. But they’re only as good as the data they’re fed.

The real win? Combining tech with human judgment. A pharmacist who knows how to dig into a patient’s history, who can call a pharmacy and say, “I need to verify this list,” and who has the time to do it-that’s the gold standard.

Why Discharge Is the Most Dangerous Moment

Most medication errors happen when patients leave the hospital. Why? Because that’s when the handoff breaks down.

The patient gets a discharge summary with a new list. But they don’t understand it. Their primary care doctor never gets it. Their pharmacy doesn’t have the updated list. The family doesn’t know what changed.

One study found that 78% of transition errors come from communication gaps between providers. Another showed that only 28% of facilities consistently involve patients in reconciling their meds. And 72% of patients don’t even know why the list matters.

Here’s what works:

• Have a pharmacist meet with the patient before discharge. Not just hand them a paper. Sit down. Ask them to read the list back. Show them the pills. Use pictures if needed.
• Send the updated list to the patient’s primary care provider and pharmacy electronically-and follow up to confirm receipt.
• Give the patient a printed copy with clear labels: “New,” “Stopped,” “Changed.”
• Call the patient 48 hours after discharge. Ask: “Are you taking all your meds as instructed? Any side effects?”

Hospitals with dedicated transition pharmacists see 53% fewer adverse drug events. That’s not luck. That’s structure.

What Gets in the Way?

You’d think everyone agrees this is important. But here’s the reality:

• Time-Doctors and nurses are overwhelmed. Reconciling meds takes 15-20 minutes per patient. Most hospitals give them 8-10. So they cut corners.
• Resistance-63% of hospitals report physician pushback. “I don’t have time to do this.” “The nurse should handle it.” “We’ve always done it this way.”
• Fragmented systems-Only 37% of U.S. hospitals can electronically share medication data with community pharmacies. That means pharmacists are still calling 10 different clinics just to get a list.
• Unclear roles-The MARQUIS study found that when staff were trained to take med histories but no one was assigned responsibility, harmful errors went up by 15%.

The fix? Don’t add a new task. Embed reconciliation into existing workflows. Make it part of admission intake. Tie it to discharge planning. Assign one person-the pharmacist or a trained nurse-as the owner. And give them the time.

What’s Changing in 2025 and Beyond

The rules are tightening. The 2025 National Patient Safety Goals require verifying high-risk medications with at least two sources. The WHO’s Phase 2 of Medication Without Harm sets a target to cut harm in high-risk transitions by 30% by 2027. CMS is increasing penalties for hospitals with high readmission rates linked to medication errors.

In Australia, the Safety and Quality Health Care Commission already requires reconciliation at every transition point. In Europe, the iPRI framework is doing the same.

New tools are coming. AI assistants that flag interactions in real time. Apps that let patients upload their own med lists from home. Pharmacy-led discharge programs that follow patients for 30 days.

But the biggest change? It’s cultural. Medication reconciliation isn’t an add-on. It’s core to safe care.

What You Can Do-Whether You’re a Patient or a Provider

If you’re a patient or caregiver:

• Keep your own list-meds, doses, times, reasons. Update it every time something changes.
• Bring it to every appointment. Don’t wait to be asked.
• Ask: “What changed? Why? What should I stop?”
• Call your pharmacy and ask them to confirm your list.
• If you’re discharged, make sure you get a written list and someone explains it to you.

If you’re a provider:

• Start with the MATCH toolkit. Don’t just install an EHR module-change how you work.
• Assign a medication reconciliation lead. Usually a pharmacist.
• Build in time. Protect 15 minutes per patient. No exceptions.
• Connect with community pharmacies. Don’t assume they have your info.
• Train your team. Not just once. Every six months. Use real cases.

Final Thought: This Isn’t About Paperwork. It’s About Trust.

Medication errors during transitions don’t just cost money. They cost trust. A patient who gets sicker because their meds weren’t reviewed doesn’t just lose health-they lose faith in the system.

But when it works? When a pharmacist catches a dangerous interaction before discharge, when a patient walks out knowing exactly what to take and why-that’s when care becomes safe. That’s when healing can actually happen.

It’s not complicated. It just takes commitment. And time. And the courage to do it right-even when it’s hard.