How to Prevent Medication Errors During Care Transitions and Discharge

Every year, hundreds of thousands of patients in the U.S. are harmed because their medications don’t get properly tracked 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. The truth is, medication reconciliation isn’t just a box to check during discharge. It’s the most powerful tool we have to stop dangerous errors before they happen.

Why Medication Errors Happen During Transitions

When a patient leaves the hospital, gets moved to a rehab center, or switches from an emergency room to a primary care clinic, their medication list often gets lost in the shuffle. One study found that 60% of all medication errors occur during these handoffs. That means if you’re discharged with five new prescriptions and three old ones, there’s a very real chance your new doctor doesn’t know you’re already taking two of those same drugs. Or worse-you’re given a new blood thinner that clashes with one you’ve been on for years.

The problem isn’t always bad technology. It’s broken communication. A 2023 survey by The Joint Commission showed only 28% of healthcare facilities consistently involve patients in reviewing their own medication lists. And even when systems are in place, staff often skip steps because they’re rushed. One resident from Massachusetts General Hospital reported that her hospital’s EHR reconciliation tool adds 12 to 15 minutes per patient during admission-time most teams don’t have. So they take shortcuts. And shortcuts cost lives.

The Four Steps of Real Medication Reconciliation

Medication reconciliation isn’t just pulling up a list from a computer. It’s a four-step process that must be done right every single time:

1. Create the most accurate list possible of what the patient is actually taking right now. This means asking the patient, checking pill bottles, calling pharmacies, and reviewing old records-not just trusting what’s in the EHR.
2. Build a new list of what the patient should be taking after discharge or transfer. This includes new prescriptions, changes to doses, and medications that should be stopped.
3. Compare the two lists side by side. Look for duplicates, missing drugs, incorrect doses, and dangerous interactions.
4. Make clinical decisions based on that comparison. If there’s a conflict, talk to the prescriber. If something’s unclear, don’t guess-ask the patient or their caregiver.

This isn’t optional. It’s required by The Joint Commission’s National Patient Safety Goals. But here’s the kicker: only 42% of U.S. hospitals do this well, according to Dr. Robert Wachter of UCSF. The rest are just going through the motions.

Technology Helps-But Only If Used Right

Electronic health records (EHRs), computerized order entry systems, and barcode scanning have cut medication errors by nearly half in hospitals, according to a 2022 Cochrane review. But they’re not magic. In fact, when EHRs are poorly implemented, they can make things worse. The MARQUIS study found that during the first six months after a new EHR launch, medication discrepancies actually went up by 18%.

Why? Because systems don’t talk to each other. Only 37% of U.S. hospitals can electronically share medication data with community pharmacies. That means pharmacists often have to call each pharmacy manually-68% of them say this is their biggest frustration. And even when data flows, it’s often outdated. A patient might have stopped a blood pressure pill two weeks ago, but the hospital system still shows it as active.

The best solution isn’t just better tech-it’s better processes. The AHRQ’s MATCH toolkit, updated in 2023, gives hospitals 159 specific steps to fix this. Hospitals that used all the recommendations saw a 63% drop in errors. Those that only upgraded their EHRs? Just 41%. The difference? MATCH doesn’t just add software-it changes how people work.

Pharmacists Are the Secret Weapon

The most effective way to prevent errors at discharge? Put a pharmacist in charge. A 2023 study in the Journal of the American Pharmacists Association found that when pharmacists lead medication reconciliation during discharge, post-discharge errors drop by 57%. Hospital readmissions fall by 38% within 30 days.

Pharmacists don’t just check lists-they ask questions. They find out if the patient can afford the meds. If they understand why they’re taking them. If they’re already taking something similar at home. One pharmacist told me: “Catching a duplicate anticoagulant order that would’ve caused a major bleed is why I do this work.”

The American Society of Health-System Pharmacists (ASHP) now recommends that every hospital have dedicated transition pharmacists. Facilities that do see 53% fewer adverse drug events. Yet most hospitals still treat reconciliation as a nursing task, not a clinical specialty.

What Patients Can Do

You can’t wait for the system to fix itself. If you’re being discharged, bring your own list. Write down every pill, patch, inhaler, and supplement you take-including doses and times. Bring the actual bottles if you can. Don’t assume the hospital has it right.

Ask these three questions before you leave:

• “What medications am I supposed to be taking now?”
• “Which ones should I stop?”
• “What should I do if I feel worse or have side effects?”

A 2024 Kaiser Family Foundation survey found that 72% of patients don’t understand why medication lists matter during transitions. But among those who did participate in the reconciliation process, 85% felt more confident about their meds. That’s the power of involvement.

Implementation Is Hard-But Worth It

Getting this right takes time, money, and culture change. Most hospitals need 6 to 9 months to roll out a solid program. The MATCH toolkit recommends 12 steps, including:

• Defining clear roles-who does what? (Nurses? Pharmacists? Doctors?)
• Training staff not just on the system, but on how to talk to patients
• Embedding reconciliation into existing workflows, not adding new ones
• Allocating 15-20 minutes per patient for full review (most only get 8-10)

Physician resistance is real. A 2023 AHRQ survey found 63% of hospitals report doctors see reconciliation as a burden. But the fix isn’t more rules-it’s less friction. Make it part of the admission checklist. Put it in the discharge summary. Give pharmacists direct access to order entry. When you remove the extra steps, people do them.

What’s Changing in 2025

The National Patient Safety Goals for 2025, released in December 2024, are tightening the rules. Now, for high-risk medications like blood thinners or insulin, you must verify the list with at least two sources-not just the EHR. That means a pharmacist must confirm with the patient and a community pharmacy.

The World Health Organization’s Phase 2 of “Medication Without Harm,” launched in October 2024, sets a new global target: reduce medication-related harm by 30% in high-risk transitions by 2027. And AI tools are starting to help. MedWise Transition, cleared by the FDA in August 2024, cut discrepancies by 41% in a 12-hospital pilot by flagging interactions and dose errors automatically.

The numbers tell the story: full implementation could prevent 800,000 medication errors in the U.S. each year-and save $2.1 billion. That’s not just a cost issue. It’s a patient safety issue.

Final Thought: It’s Not About Technology. It’s About Care.

Medication errors during transitions aren’t caused by bad people. They’re caused by broken systems, rushed staff, and poor communication. Fixing them isn’t about buying the fanciest EHR. It’s about giving people the time, training, and trust to do the right thing.

The patient walking out the door doesn’t care if your system is certified or your software is new. They care that they go home with the right pills, in the right doses, with no surprises. That’s what matters. And that’s what we can fix-if we choose to.