We need only take a glimpse into the magnitude of medication errors to realize the increasing need to effectively control such errors.  Understanding that approximately 82% of American adults take at least one medication—and 29% take five or more medications—we see adverse drug events (ADEs) causing about 1.3 million emergency department visits and 350,000 hospitalizations each year in the United States. 

Medication errors can occur at any point in the medication process—including prescribing, communicating, compounding, labeling, dispensing, delivery, and administration—but are indeed preventable events.  When an error does occur, one needs to look at both how it happened and why it happened, but the real key lies in understanding the ‘why’ and putting a process change in place to prevent it from occurring in the first place.  One of the best strategies for preventing errors involves medication reconciliation. 

Medication reconciliation during transitions of care, such as when a resident enters a new care setting, is of utmost importance.  To prevent errors such as omissions, duplications, dosing mistakes, or drug interactions, the process for obtaining and documenting a complete and accurate list of a patient’s current medications upon admission/move-in and comparing this list to the prescriber’s admission, transfer, and/or discharge orders is key to identifying and resolving discrepancies. Experts recommend the following process be conducted at EVERY transition of care in which new medications are ordered or existing orders are rewritten:

• Verify medications taken at home (Best Possible Medication History or BPMH).
• Reconcile home medications with those ordered on admission/move-in.
• Reconcile home medications with those ordered on discharge.
• Reconcile home medications with those ordered on transfer.

For a handy checklist of important actions to take at all process points in LTC and senior care, download our tip sheet: Reducing Medication Errors in Long-Term & Senior Care.