Preventing medication errors in transitions of care: A...

www.pharmacist.com MARCH 2015 • PharmacyToday 1

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-15-117-H05-P.

Disclosures: Ashley Johnson, Yasmin Grace, and Erenie Guirguis and APhA’s editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the APhA Accreditation Information section at www.pharmacist.com/education.

Development: This home-study CPE activity was developed by the American Pharmacists Association.

Abstract

Objective: To discuss common causes of medication errors occurring upon transitions of care and review key interventions that should be implemented to ensure effective communication and accurate completion of medication reconcili-ation.

Data sources: MEDLINE (1946 to November 2014) using MeSH terms medi-cation errors, medication reconciliation, and nursing homes in addition to con-ventional text words, including transitions of care and medication safety; Agency for Healthcare Research and Quality Patient Safety Network using search terms transitions of care, medication errors, and medication reconciliation; and relevant websites of national organizations pertaining to transitions of care and medication reconciliation.

Study selection: Limited to English-language journals with no limitation set on the year of publication for clinical trials, meta-analyses, and reviews.

Data extraction: At the authors’ discretion, preference was given to references focusing on pharmacists’ role in transitions of care and medication reconciliation.

Results: Most medication errors stem from a lack of effective communica-tion between health care providers during transitions of care. Part of successful communication and correct patient hand-off is completing accurate medication reconciliation. A patient case highlights a life-threatening medication error that occurred during a transition of care due to ineffective communication between a pharmacist and nurse while transferring medication information.

Conclusion: To provide patients with accurate medication information, phar-macists should perform medication reconciliation upon transitions of care using The Joint Commission’s five-step process. Pharmacists can conduct numerous interventions to prevent medication errors during transitions of care and ensure patient safety. Pharmacists are integral to evaluating the appropriateness of med-ication use, ensuring information is updated in the health record, and verbally communicating accurate information to other health professionals.

Pharm Today. 2015;21(3):XX–XX.doi: 10.1331/JAPhA.2015.15509

CPE

Accreditation informationProvider: American Pharmacists AssociationTarget audience: PharmacistsRelease date: March 1, 2015Expiration date: March 1, 2018Learning level: 1

ACPE number: 0202-0000-15-117-H05-PCPE credit: 2 hours (0.2 CEUs)Fee: There is no fee associated with this activ-ity for members of the American Pharmacists Association. There is a $25 fee for nonmembers.

Preventing medication errors in transitions of care: A patient case approachAshley Johnson, Erenie Guirguis, and Yasmin Grace

Ashley Johnson, PharmD, BCPS, Assistant Professor of Pharmacy Practice and Drug Information Co-Coordinator, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL

Erenie Guirguis, PharmD, BCPS, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL

Yasmin Grace, PharmD, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL

Correspondence: Ashley Johnson, PharmD, BCPS, Assistant Professor of Pharmacy Practice, Palm Beach Atlantic University, 901 S. Flagler Drive, West Palm Beach, FL 33416; [email protected]

Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article.

Reprinted from the Journal of the American Pharmacists Association (www.japha.org) and available for continuing pharmacy education credits at www.pharmacist.com/education.

Learning objectivesAt the conclusion of this knowledge-based activity, the pharmacist will be able to:

■ Recognize the common causes of medication errors occurring during transitions of care.

■ State The Joint Commission National Patient Safety Goal related to communi-cation of medication information.

■ List the components within the medica-tion reconciliation process that should be assessed during transitions of care.

■ Identify barriers to implementing an appropriate medication reconciliation process.

■ Recommend interventions for phar-macists to prevent medication errors during transitions of care.

www.pharmacytoday.org2 PharmacyToday • MARCH 2015

CPE TRANSITIONS OF CARE

Medication errors are a large burden to the U.S. health care system, causing avoidable hospital admissions and pro-longed hospital stays. The majority of these avoidable ad-verse events are due to the lack of effective communication between health care providers. An estimated 80% of serious medical errors involve miscommunication during hand-off between medical providers.4 Recently, The Joint Commission Center for Transforming Healthcare has been highlighting the importance of improving transitions of care by concen-trating on hand-off communications.5 Part of successful com-munication and correct patient hand-off is completing accu-rate medication reconciliation across the continuum of care.6

The patient case (see sidebar) serves to highlight a life-threat-ening medication error that occurred during a transition of care due to ineffective communication between a pharmacist and nurse while transferring medication information.

ObjectivesThe goal of this article is to discuss common causes of medi-cation errors upon transitions of care and to review key in-terventions that should be implemented to ensure effective communication and accurate completion of medication rec-onciliation.

Search methodologyRelevant literature was identified by performing a MEDLINE search (1946 to November 2014) using the MeSH terms medi-cation errors, medication reconciliation, and nursing homes in addition to conventional text words, including transitions of care and medication safety. A search of the Agency for Healthcare Research and Quality Patient Safety Network collection was also performed using the search terms transi-tions of care, medication errors, and medication reconcilia-tion. Relevant websites of national organizations pertaining to transitions of care and medication reconciliation were also included. The search was limited to English-language

Preassessment questionsBefore participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment.1. What is the estimated percentage of medication errors that occur

during transitions of care? a. 20%b. 40%c. 60%d. 80%

2. What strategy helps prepare patients for appropriate transitions at hospital discharge in order to prevent hospital readmissions?a. Performing medication reconciliation after dischargeb. Providing physician-centered education c. Preemptively scheduling outpatient visitsd. Providing discharge instructions to the patient only

3. Which is a barrier to providing appropriate medication assess-ment and reconciliation?a. Well-aligned workflowb. Misaligned financial incentives of health care institutionsc. Increased perception of the importance of a medication listd. High reliability of the health care system

Overview of the patient case An 84-year-old woman with a complicated medical history of atrial fibrillation, chronic heart failure, hypertension, and chronic hypokale-mia was transported to the emergency department at a general medi-cal and surgical hospital from a nearby long-term care facility. She presented with shortness of breath, moderate respiratory distress, and altered mental status. The long-term care facility staff reported that the patient had new-onset shortness of breath and altered mental status of unknown origin. According to the nursing staff, upon admission to the facility a few days before, she had normal mentation that quickly worsened. Upon arrival to the emergency department, her condition deteriorated rapidly, with electrocardiogram changes including prolonged QT intervals and peaked T waves and respira-tory failure requiring emergent intubation. A basic metabolic panel on admission revealed an elevated serum potassium of 7.2 meq/L, elevated blood urea nitrogen (BUN) of 44 mg/dL, and elevated serum creatinine (Scr) of 2.53 mg/dL, all correlating with a quickly diag-nosed acute kidney injury. Additional lab findings of concern included a low serum albumin of 1.8 g/dL. Upon investigation in the emer-gency department, the patient’s husband was contacted, and it was discovered that the patient was living independently with her husband before admission to the long-term care facility. Medication reconcili-ation was completed upon admission to the long-term care facility between a nurse and a pharmacist at a local community pharmacy. The nursing facility medication list included digoxin 0.25 mg daily.

After further discussion with her husband, it was discovered that the patient’s cardiologist had discontinued the use of digoxin more than 2 years ago. It appeared that it was also the last time digoxin had been dispensed by the community pharmacy. It was confirmed that the patient was incorrectly given digoxin 0.25 mg daily while at the long-term care facility. Lab tests revealed a digoxin level of 7.5 ng/mL, and the patient was subsequently diagnosed with digoxin toxicity. The patient was administered one dose of digoxin immune Fab(Digibind) 800 mg/50 mL at a rate of 100 mL per hour intrave-nously. The patient progressed to have a complicated admission with a problem list that included digoxin toxicity, acute respiratory failure, acute kidney injury, and Clostridium difficile infection. She was eventually extubated and discharged after a 9-day hospital stay to a post–acute care facility for physical rehabilitation.

Several factors played a role in propagating this preventable medication error that resulted in patient harm. The patient’s creati-nine clearance upon admission to the emergency department was calculated to be 6 mL/min based on the Cockcroft–Gault equation, in which case a dose of digoxin 0.25 mg daily is inappropriate. When indicated for patients with atrial fibrillation, the recommended oral maintenance doses of digoxin range from 0.125 mg to 0.375 mg (125 mcg to 375 mcg) daily; however, as renal function declines, so does the recommended dose.1 In addition, during periods of acute kidney injury, the administration of digoxin is not recommended.1–3 This was compounded by many other patient factors that increased the risk of digoxin toxicity, which should have been noted during the patient assessment upon admission to the long-term care facility. Some of these factors included advanced age, concurrent use of loop diuretics (the patient had been taking bumetanide 1 mg twice a day), and a history of chronic hypokalemia. During communications between the community pharmacist and the nurse at the long-term care facility, the pharmacist stated every medication on the patient’s medication profile that had ever been filled at the pharmacy. The nurse assumed all medications listed were current and initiated them at the long-term care facility. This communication error ultimately resulted in life-threatening digoxin toxicity resulting from inappropriate medication. While this medication error resulted in an extended hospital stay, after intensive care the patient returned to baseline mental function and restored heart rhythm.


TRANSITIONS OF CARE CPE

journals, with no limitation set on the year of publication for clinical trials, meta-analyses, and reviews.

Common causes of medication errors during transitions of careThe National Transitions of Care Coalition defines a transi-tion of care as “the movement of patients between health-care locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the pa-tient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”7 During care transitions, not only does the setting change, but the person responsible for health care de-cisions also changes, necessitating clear communication to ensure quality care.8

An estimated 60% of all medication errors occur during transitions of care.7,9 An increased risk of medication errors occurs when a patient transitions from the hospital to the ambulatory care setting if complete information is not avail-able and if multiple health professionals are providing care.10 Failure to implement safeguards within care transitions can lead to adverse events and higher rates of rehospitalization.11

Poor communication during transitions of care is responsible for roughly one-half of all hospital-related medication errors and one-fifth of all adverse drug events.12

During care transitions, inadequate communication can lead not only to medication errors but also to delays in care, inappropriate monitoring, overall confusion about the care a patient is receiving, and increased health care expendi-tures.7 A closer examination of best practices to ensure safe care transitions for the older adult population is of particular importance given that older adults account for a substantial proportion of transitions and are prone to developing com-plications from the care they receive.13 While many transi-tions occur within the hospital setting, this article will focus primarily on transitions to a health care facility from the am-bulatory care setting and transitions within the ambulatory care setting.

Care transitions from acute health care facilitiesVirtually all care transition models have three core compo-nents: medication management, communication, and patient education. A variety of care transition models have been re-searched extensively and include published toolkits to assist in effective transitions of care upon discharge from hospitals (also referred to as acute health care facilities). Examples in-clude Project RED (Re-engineered Discharge), implement-ed at Boston University Medical Center; H2H (Hospital to Home) Project, endorsed by the Institute for Healthcare Im-provement (IHI) and the American College of Cardiology; and BOOST (Better Outcomes for Older Adults through Safe Transitions).8

Various interventions have been implemented to as-sist in reducing readmissions following hospital discharge. Performing medication reconciliation, providing patient-centered education, and preemptively scheduling outpatient

visits before discharge can help prepare patients for the tran-sition. In addition, using health care team members to guide patients with specific instructions helps to facilitate the dis-charge process. Last, interventions—including a telephone follow-up call, access to timely follow-up with a primary care provider, availability of a patient hotline, and visits to patients’ homes—serve to mitigate issues encountered post-discharge.8

Care transitions to and from postacute health care facilitiesTransfer to or from postacute health care facilities such as nursing facilities, assisted living facilities, and rehabilitation centers come with inherent risks, such as potential rehospi-talization and medication errors.9 Patients who are older than 65 years of age, taking multiple medications, cognitively im-paired, lacking a support system, and/or living with chronic conditions may be at increased risk of adverse events and suboptimal medication use during transitions of care.9,14,15

The Demonstration Project Initiative in Nursing Facili-ties in Greensboro, NC, reported finding an average of 2.7 medication discrepancies per patient, with 6% of those deemed high risk to cause significant patient harm.16

In a single-blind, randomized, controlled trial investigat-ing the use of pharmacist-based medication review for pa-tients transitioning from the hospital to a long-term care fa-cility, patients who received the medication review compared with usual care experienced an improvement in appropriate medication use, as shown by the Medication Appropriateness Index (MAI) score.17 The MAI score uses 10 criteria to assess the appropriateness of a prescribed medication in older adult patients. The 10 criteria include indication, effectiveness, dose, correct directions, practical directions, drug–drug in-teractions, drug–disease interactions, cost, unnecessary du-plication with other drugs, and duration of therapy.17,18

In another study, Boockvar and colleagues assessed medication reconciliation performed within 24 hours of ad-mittance to a long-term care facility from a hospital. Results from this study noted that medications, including analgesic, cardiovascular, and psychiatric agents, were not appropri-ately continued once patients were admitted to the long-term care facility.19 Use of a standardized transfer form between postacute care facilities and hospitals has been helpful in communicating information and in reducing the time re-quired to collect medication information.20 Another option to reduce errors associated with care transitions is to avoid the transition out of long-term care facilities by providing ex-panded health care services at the patient’s current location.13

Errors of omission are more likely during intensive care of patients who are initially admitted to the hospital from an outpatient setting or another health care facility. During an

Case highlightWhat caused the medication error in the patient case?

The medication error was a result of miscommunication occur-ring during medication reconciliation between the admitting nurse at the long-term care facility and a community pharmacist.



acute episode, medications for chronic conditions often are unintentionally discontinued and not appropriately restart-ed. In an observational study, unintentional discontinuation of statins and anticoagulants/antiplatelets was associated with an increased risk of death, hospitalizations, and emer-gency department visits for 1 year after hospital discharge.21

The Joint Commission National Patient Safety GoalsThe Joint Commission originally introduced medication rec-onciliation as a National Patient Safety Goal (NPSG) in 2005. Since that time many changes have occurred. The current NPSG 03.06.01 for ambulatory health care, “Maintain and communicate accurate patient medication information,” con-tains five elements of performance (Table 1).22 New in 2014 was a requirement to inform patients about the importance of maintaining updated medication information. When pa-tients are discharged from a health care facility or at the end of an outpatient visit, pharmacists should instruct patients to update their medication list with any new changes, share this list with all of their health care providers, and discard any old medication lists. It is also prudent to encourage pa-tients to carry their medication information with them, spe-cifically in case of emergencies.22

Medication reconciliation is recognized as an important process to ensure medication accuracy at care transitions as part of the World Health Organization’s Action on Patient Safety (High 5s) initiative. IHI also encourages implemen-tation of medication reconciliation to prevent adverse drug events as a component of the organization’s 100,000 Lives Campaign.23,24

Completing medication reconciliation There is an urgent need for effective processes that address inadequacies in obtaining and communicating accurate medication lists. An estimated two-thirds of prescription medication histories have errors, and multiple unintended medication discrepancies have been reported upon hospital admission.12,25 Pharmacist involvement in assessing medica-tion use has been shown to reduce outpatient visits, length of hospital stay, and health care costs.

The American Pharmacists Association (APhA) and the American Society of Health-System Pharmacists (ASHP)

define medication reconciliation as “the comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication er-rors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adher-ence patterns. This process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are rewritten or adjusted, or if the patient has added nonprescription medication to [his or her] self-care.” In other words, medication reconciliation is the process of creating the most accurate and complete list of medication information.

The intent of performing what can be a complex and at times challenging process is to address and resolve any discrepancies to ensure safe and effective use of medica-tion therapies. Medication discrepancies may be caused by failure to obtain the best possible medication history or by incomplete prescriptions, or they may occur if a medication was unavailable at a particular health care facility and no re-placement was provided.26

It is difficult to obtain an accurate and complete medica-tion list for every patient because doing so is contingent upon the patient’s ability to provide the necessary information.22

The process can be further complicated when care is provid-ed by multiple health professionals. Estimates show that pa-tients with chronic conditions may receive care from up to 16 physicians annually.27 With education and training special-izing in medication information, pharmacists are equipped with the knowledge to identify and resolve any medication discrepancies encountered during medication reconcilia-tion. Furthermore, in a study comparing pharmacist- versus physician-obtained medication histories, pharmacists identi-fied significantly more preadmission medications than did physicians.28

The Joint Commission recommends a five-step process to conduct medication reconciliation. First, develop a com-prehensive list of all current medications to create the best possible medication history. Medication reconciliation should include an assessment of all medication information, including all prescription and OTC medications, vitamins, and dietary supplements along with the dose, frequency, route, and when the last dose was taken. If possible, inves-

Table 1. The Joint Commission National Patient Safety Goal 03.06.01 for ambulatory health care—Maintain and communicate accurate patient medication information: Five elements of performance Element no. Element description

1Obtain and/or update information on the medications the patient is currently taking. This information is documented in a list or other format that is useful to those who manage medications.

2 Define the types of medication information to be collected in different settings and patient circumstances.

3For organizations that prescribe medications: compare the medication information the patient brought to the organiza-tion with the medications ordered for the patient by the organization in order to identify and resolve discrepancies.

4For organizations that prescribe medications: provide the patient (or family as needed) with written information on the medications the patient should be taking at the end of the care episode (e.g., name, dose, route, frequency, purpose).

5For organizations that prescribe medications: explain the importance of managing medication information to the patient at the end of the care episode.

Source: Reference 22.



tigate the patient’s adherence to the medication regimen, as patients may not be actively taking all medications listed on their profile or electronic health record. Taking time to check a patient’s refill history may also prove helpful in identify-ing which medications a patient is actively taking. Involving other health care providers such as community pharmacists, specialists, and primary care providers can also help to en-sure all medication information is retrieved and to verify the information provided by the patient. Sources that can be used to verify medication information include community pharmacies, medication vials, electronic health records, and physicians, to name a few.

In the second step of the process, develop a list of medi-cations to be prescribed. This list should include all medi-cations necessary for the management of both acute and chronic conditions, unless contraindicated. Medications to be prescribed should be in accordance with current evi-dence-based medicine guideline recommendations. Patient preferences, values, experiences with previous medications, and allergies should be carefully considered when deter-mining which medications are best suited for an individual. Third, compare the original and updated medication lists. This key step is necessary to prevent therapeutic duplication of medications, especially given that most hospitals adhere to formulary restrictions that require the standardized use of certain medications, and to make certain that each medical condition has been appropriately addressed.

The fourth step is to make clinical decisions pertaining to which medications should be continued. Decision mak-ing should take into consideration the potential presence of drug–drug interactions, potential adverse drug reactions, and medication regimen complexity. Simplifying the final-ized medication regimen can facilitate the appropriate use of medications and adherence to prescribed medications.

The last step is to communicate the new medication in-formation to the patient, the patient’s caregivers, and other health professionals involved in the patient’s care.12 Commu-nicating information in both verbal and written forms can be helpful. Multiple copies of the medication information should be provided to the patient or caregivers so that the in-formation can be shared with other health professionals and pharmacy providers. All forms of communication should be tailored to meet individual patient needs as much as possible (Table 2).

While the intent of conducting medication reconciliation is to reduce medication errors, a new error, classified as a reconciliation error, may occur when a discrepancy is found but not resolved by a health professional. Factors that con-tribute to reconciliation errors include advanced patient age, incomplete medication history, patient’s poor understanding of medications, patients with numerous medical records, ex-tended hospital stays, presence of multiple comorbid condi-tions, use of multiple medications, and care transitions oc-curring during weekends.26

It may be especially important to exert caution if a pa-tient is taking high-risk medications. The Institute for Safe Medication Practices (ISMP) classifies high-alert medica-

Case highlightWhat steps of appropriate medication reconciliation were missing in the patient case presented?

The first step of developing a list of current medications was lacking. This is evident because medications the patient was no longer taking were included in her medication profile. In addition, the final step of communicating new medication information with caregiv-ers was not performed until the patient experienced an adverse drug reaction from inappropriate digoxin use, leading to hospitalization.

Case highlightWhat patient risk factors may have contributed to the medication error?

The patient was being admitted to a postacute health care facility when the medication error occurred as a result of miscom-munication. The patient’s many risk factors included advanced age, use of multiple medications, and numerous chronic comorbidities. Furthermore, because the postacute health care facility did not use a standardized transfer form to collect information from the community pharmacy, the information was communicated verbally but not veri-fied for accuracy. The error occurred with a high-alert cardiovascular medication (digoxin) that can cause significant patient harm if used inappropriately. Also, a pharmacist was not available at the postacute health care facility to complete the medication reconciliation with the community pharmacist.

tions as those that have the propensity to cause significant patient harm if used inappropriately. Medications that are deemed high alert within the community and ambulatory care setting include antiretroviral, chemotherapeutic, hypo-glycemic, and immunosuppressant agents; insulin; opioids; liquid pediatric medications that require measurement for administration; and pregnancy category X medications.29–31 Some common high-alert medications that patients may re-ceive in the acute care and post–acute care settings include antiarrhythmics, antithrombotic agents, and sedatives. ISMP recommends that the use of high-alert medications be stan-dardized and safeguards such as double checks be imple-mented as appropriate (Table 3).29−31 In addition, if a discrep-ancy is found with a high-alert medication, the issue should be resolved promptly within a specified time frame to reduce harm.

Recommending a standardized form for patients to maintain their medication information may help to mini-mize incomplete medication histories and improve patients’ understanding of their medications. Numerous universal medication forms published by national organizations can be modified electronically in a Word document or printed out to manually record pertinent medication information by either a patient or a health professional.29,32–34 With many op-tions available, it is best to opt for the form that best meets in-dividual patient needs, is consistent with the patient’s health literacy, and is in the patient’s native language.

The IHI’s universal medication form is a concise two-page document designed to collect information on allergies, immunization history, and medication use, including the name of medications, dose, directions, date stopped, reason for taking, and physician name.32 Patients are encouraged to use the form to better understand their medications, save



time, enhance communication among health care providers, and improve the safe use of medications.32 ISMP’s Personal Medicine Form is similar to the IHI form but also contains areas to record height, weight, and contact information for the health care provider(s) and pharmacy. In addition, a re-minder lists not only tablets but also drops, inhalers, injec-tions, liquids, ointments, and patches since some patients may forget to include these medications.29

ASHP has developed My Medicine List, a form provid-ing detailed, patient-friendly instructions on how to create a medication list organized by medications that are taken in the morning, afternoon, evening, and before bedtime, and those that are not used daily.33 My Medicine List also offers space for patients to describe what the medication looks like (e.g., shape, color, tablet or capsule), potential medication problems they may be experiencing, and questions they may have for their health professionals.33 A unique aspect of My Medicine List is its availability in other languages, including Spanish and French.33

Last, the Agency for Healthcare Research and Quality has created a pill card that may be particularly helpful for patients with low health literacy or limited cognitive abili-ties. The pill card includes specific instructions on how to create a simplified medication list and clip art illustrating what medications look like, when to take them, and what they are used for.34 Regardless of the medication form se-lected, encourage patients to always keep their medication form with them, to provide a copy to family members and/or caregivers, to routinely update the form after any medica-tion changes, and to discard any outdated medication lists. These tools can empower patients to take ownership of their medication information and be involved with the medication reconciliation process.

After the patient has created a current medication list, use the teach-back method to assess the patient’s understanding of the medications by asking six targeted questions (Table 4).35 As time permits, ask open-ended questions to determine if the patient has full understanding, avoid using medical jargon, and focus on take-home educational messages.

To ensure effective medication reconciliation occurs, pharmacists should adopt an interprofessional approach involving other members of the health care team, such as physicians, nurses, and specialists. In the words of Eric A. Coleman, “Care transitions is a team sport, and yet all too of-ten we don’t know who our teammates are, or how they can help.”36 Each person involved should have clearly defined roles and responsibilities and should understand how these responsibilities may change depending upon the setting and patient.

Effective communication is yet another essential compo-nent of the medication reconciliation process. After perform-ing medication reconciliation, the patient, current health professional, and the next health professional should all be provided with documentation of the most recent medication information so as to avoid any gaps in communication.12 Dur-ing a care transition, future health professionals responsible for providing care should be informed of the reason for dis-

charge or care transition and the patient’s physical and psy-chosocial status. In addition, they should be provided a sum-mary of care, progress toward goals, resources or referrals as applicable, and a list of current medications, including any allergies.37 Communication of any cultural factors, health lit-eracy needs, financial factors, environmental concerns, and lack of support systems that may impede progress toward improving health goals should also take place during transi-tions of care.35 It is best not to rely solely on patients for re-laying medication information and discharge summaries to their primary care provider. The information is more likely to reach the primary care provider if it is e-mailed or faxed directly.38 Additional information to be provided upon trans-fer of care includes detailed medication changes (Table 5).24

Upon implementing a medication reconciliation pro-cess, health professionals should continuously evaluate its functionality and accuracy and identify potential areas for improvement.12 The intent of performing medication recon-ciliation is not only to create a list of a patient’s current medi-cations but also to provide an opportunity to make meaning-ful changes to medication therapy as warranted.

To date, there has been limited research to assess the im-pact of conducting medication reconciliation within the pe-diatric population. Further evidence is needed to establish best practices for minimizing medication discrepancies in this patient population.39

Table 2. The Joint Commission’s five-step process to conduct medication reconciliationStep no. Step description

1Develop a comprehensive list of all current medica-tions.

2 Develop a list of medications to be prescribed. 3 Compare original and updated medication lists.

4Make clinical decisions pertaining to what medica-tions should be continued.

5Communicate the new medication information to patient and patient’s caregiver.

Source: Reference 12.

Table 3. Examples of high-alert medicationsCommunity and ambulatory care

Acute and postacute care facilities

Carbamazepine Epinephrine, subcutaneousChloral hydrate liquid, for sedation of children Insulin U-500Low molecular weight heparin Magnesium sulfate injectionUnfractionated heparin Methotrexate, oral; nononcologic use Metformin Opium tinctureMethotrexate, nonon-cologic use Oxytocin, I.V.Midazolam liquid, for sedation of children Nitroprusside sodium for injection

PropylthiouracilPotassium chloride and phosphates for injection

Warfarin Promethazine, I.V.Vasopressin, I.V. or intraosseous



Barriers to medication reconciliationInsufficient staffing and time constraints are among the top barriers that limit successful integration of medication recon-ciliation across transitions of care. The emphasis on produc-ing timely orders within an institution and quickly prepar-ing and dispensing prescriptions in the community setting comes to the detriment of ensuring medication orders are accurate and comprehensive. A meta-analysis investigating medication reconciliation performed during hospitalization found that pharmacists were an integral element in success-ful interventions.40 Kwan and colleagues noted that targeting high-risk populations for medication reconciliation did not result in decreasing the prevalence of clinically significant unintentional discrepancies.40 Despite these findings, if lim-ited resources are a concern, one suggestion for pharmacist-conducted medication reconciliation is to give priority to patients who have multiple comorbid conditions, those who take multiple or high-risk medications, or those with whom it is difficult to acquire the best possible medication history.26

Difficulties in obtaining medication information due to language barriers, as well as a lack of health care provider knowledge about medications, are other barriers that impede the medication reconciliation process.15 A lack of available electronic health records exists across the continuum of care among community pharmacies, ambulatory care clinics, and hospitals, disrupting the seamless transition of crucial infor-mation.41 Even with access to electronic health records, a lack of a standardized approach to entering medication informa-tion may hinder dissemination of accurate information.12

Complicating matters upon transitions is some institutions’ use of different discharge forms depending on whether the patient is transitioning to a nursing facility, an assisted living facility, or home.16 Furthermore, it can be difficult to contact a prescribing physician at a hospital or long-term care facil-ity to verify or address concerns about medication orders, especially after hours and on the weekends. A propensity to believe that medication information provided by another health care facility is both complete and accurate may create a false sense of security.16 This in turn may decrease the like-lihood that health professionals will take on additional tasks to verify medication orders or rectify discrepancies.

Other barriers cited by APhA and ASHP include “dupli-cative and additive workflow, misaligned financial incen-tives across the continuum of care, low reliability of the cur-rent healthcare system, misperception of increased liability, lack of evidence to validate the importance of the medication list, and failure by the public to adopt the list.”12

Pharmacist interventions during transitions of careNursing facilitiesWithin certain types of long-term care facilities, a consultant pharmacist is required by the Centers for Medicare & Medic-aid Services (CMS) to conduct a medication regimen review at least monthly to identify and resolve any medication-relat-ed issues.16 Pharmacists play an integral role within nursing facilities by performing medication reconciliation and medi-

cation reviews, following up with patients via telephone calls approximately 1 week after discharge, contacting physicians to resolve any identified medication discrepancies, and con-tacting the patient and/or caregivers to communicate any changes in their medication regimen.15 Pharmacists and pharmacy technicians have assisted patients throughout the transition process through the use of call centers that have personnel devoted to specifically addressing transition is-sues.42

Ambulatory careSen and colleagues have described use of a postacute care clinic (PACC) model to provide follow-up to patients tran-sitioning to the outpatient setting after hospital discharge to address any issues that may contribute to inappropriate medication use.43 This PACC model uses an interdisciplinary team approach involving a pharmacist, an attending physi-cian, at least two internal medicine residents, and a social worker. The pharmacist’s role within the team is to review medication changes throughout the full spectrum of transi-tions, evaluate for appropriate use, and ensure updated in-formation is communicated both within the electronic health record and verbally with other health professionals.

Challenges cited in using the PACC model include edu-cating health professionals on its role, scheduling issues, space limitations, and time constraints. In efforts to maxi-mize limited time with patients, pharmacists may review medication lists and the discharge summary before meeting with the patient.43

Table 4. Teach-back method: Question series to discuss with patients about medication useQuestion no. Question

1Why are you taking each of the medications pre-scribed to you?

2What are the positive effects of taking each medi-cation?

3What adverse effects may occur with each medica-tion you use?

4Where should your medications be stored at home?

5 When are your medications due to be refilled?

6How long should you be taking your current medications?

Table 5. Communication of medication changes upon transfer of care (High 5s project) New medicationsDiscontinued medications Adjusted medications Unchanged medications to be continued Medications held in hospital Nonformulary/formulary adjustments New medications started on discharge Additional comments as appropriateSource: Reference 24.



Community pharmacyWithin transitions of care, often the resources provided by community pharmacists are underused. In another model described by Sen and colleagues, a local community phar-macy collaborated with a community hospital to provide complete medication management postdischarge and com-plimentary delivery of medications to either the hospital or the patient’s home.43 Pharmacists then followed up within 72 hours to offer services and discuss any medication-related questions and adherence issues. If the patient agreed to the services, a pharmacist would have dedicated time with the patient to review the medication information thoroughly and provide individualized education that would then be electronically documented so the information could be com-municated with the patient’s primary care physician.

Challenges encountered in this model included recruit-ing patients for the services, high no-show rates, and lack of access to discharge summaries. Factors that may further improve transitions of care in the community setting are increasing the number of community pharmacies offering transitions of care services, providing incentives to patients to encourage them to use these services, having access to patient medication information including refill histories through insurance companies, and receiving reimbursement for services provided.43

Information technology Another innovative method currently being explored is the use of virtual ambulatory medication reconciliation via se-cure messaging.44 Secure messaging allows the health pro-fessional and patient to communicate using secure e-mail that is accessed within a patient Web portal. This method was evaluated in an observational study conducted in the U.S. Department of Veterans Affairs’ primary care clinics. While this intervention provides a unique avenue to quickly communicate with patients, it may have limited applicability in patients with low health literacy, those without Internet ac-cess, or those uncomfortable communicating electronically with the health care team.44 Use of self-service kiosks linked to electronic health records has also been explored as an al-ternative option to conducting medication reconciliation.44

A review conducted by Bassi and colleagues evaluating the use of information technologies throughout the medica-tion reconciliation process found that use of e-mails, elec-tronic health records, electronic decision tools, and comput-erized physician order entry has helped health professionals obtain medication information, compare medication infor-mation upon transitions, and identify discrepancies.45

Patient involvement Involving patients, family, and/or caregivers in the medi-cation reconciliation process and including them as active members of the health care team is essential. It is helpful to keep in mind that often the patients and/or caregivers are the only constant during care transitions.46 As patients and caregivers navigate this complex process, pharmacists can inform them of their rights during transitions of care (Table

Case conclusion In the patient case, what ultimately resulted in the medication error?

Communication error between the community pharmacist and admitting nurse resulted in restarting a high-alert medication that had been discontinued by the patient’s cardiologist.In reviewing the five-step process provided by The Joint Commission, which steps were not completed or completed incorrectly?

■ Step 1: A comprehensive list of the patient’s current medications was not acquired appropriately. The patient was not on digoxin currently.

■ Step 4: Although the outpatient medication list was incorrect, the nursing facility should have identified that several factors made the patient a poor candidate for digoxin therapy, including advanced age, reduced renal function, concurrent use of loop diuretics, and chronic hypokalemia.

■ Step 5: The error also could have been prevented by communicat-ing the new medication list created in the nursing facility with the patient or her husband so they could have provided an accurate reporting of the most current medication list.

What changes would you recommend to prevent future similar medica-tion errors?

Encourage health care facilities such as long-term care facilities to have a pharmacist responsible for completing accurate medication reconciliation upon transitions of care. All health care providers should receive training on properly communicating patient information.

6), direct them to medication information designed for pa-tients, and help them prepare questions to engage in conver-sation with their primary care providers.46

If possible, encourage patients to use a single pharmacy to fill prescriptions. This may not always be feasible with cer-tain third-party payers that require the use of mail-service pharmacies for select medications and with differing out-of-pocket costs at pharmacies for uninsured patients.

ConclusionThe most common cause of medication errors upon transi-tions of care is poor communication.12,14 Transitions of care include moving patients from acute health care facilities to postacute health care facilities, from postacute health care fa-cilities to acute health care facilities, from home to health care facilities, and from health care facilities to home. To provide patients with accurate medication information, it is impor-tant for health care professionals, particularly pharmacists, to perform medication reconciliation upon transitions of care using the Joint Commission’s five-step process.

Despite the importance of communicating clearly and ac-curately during transitions of care and completing accurate medication reconciliation as part of the process, many barri-ers still exist to accomplishing these goals. Although these barriers may be discouraging, pharmacists can conduct nu-merous interventions to prevent medication errors during transitions of care and ensure patient safety. CMS requires consultant pharmacists to conduct a medication regimen re-view at least monthly. Performing these necessary medica-tion reconciliations allows pharmacists to play an essential role within nursing facilities. Pharmacists can also ensure that after discharge from an acute care facility, patients have a scheduled follow-up appointment in the outpatient setting, therefore promoting continuity of care.43 Health care facili-



ties should also support the participation of pharmacists as members of the interdisciplinary team to review medication changes throughout transitions of care. Pharmacists are inte-gral within the team in order to evaluate the appropriateness of medication use, to ensure information is updated in the health record, and to verbally communicate accurate infor-mation to other health professionals.

In the community setting, pharmacists should be en-couraged to conduct a postdischarge medication reconcilia-tion to ensure an updated and accurate list of medications is obtained and to discuss medication changes with the pa-tient within 72 hours of discharge so the patient clearly un-derstands them.43 Last, it is vital that pharmacists encourage patients, family members, and caregivers to be involved with the medication reconciliation process as active members of the health care team.33

References1. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline

for the management of heart failure: a report of the American Col-lege of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327. doi: 10.1161/CIR.0b013e31829e8776.

2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guide-line for the management of patients with atrial fibrillation: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246–2280. doi: 10.1016/j.jacc.2014.03.022.

3. Aronoff GR, Bennett WM, Berns JS, et al. Drug prescribing in renal failure: dosing guidelines for adults and children. 5th ed. Philadel-phia: American College of Physicians; 2007.

4. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communica-tion during patient hand-offs. Acad Med. 2005;80(12):1094–1099.

5. Joint Commission Center for Transforming Healthcare. Improving transitions of care: hand-off communications. Center for Transform-ing Healthcare website. http://www.centerfortransforminghealth-care.org/assets/4/6/CTH_Handoff_commun_set_final_2010.pdf. Accessed December 10, 2014.

6. The Joint Commission announces the 2006 National Patient Safety Goals and requirements. Jt Comm Perspect. 2005;25(7):1–10.

7. National Transitions of Care Coalition. Improving transitions of care: findings and considerations of the “Vision of the National Transitions of Care Coalition.” National Transitions of Care Coalition website. http://www.ntocc.org/portals/0/pdf/resources/ntoccissuebriefs.pdf. Accessed December 9, 2014.

8. Wittkowsky AK. Impact of target-specific oral anticoagulants on transitions of care and outpatient care models. J Thromb Throm-bolysis. 2013;35(3):304–311.

9. Kirwin J, Canales AE, Bentley ML, et al. Process indicators of qual-ity clinical pharmacy services during transitions of care. Pharmaco-therapy. 2012;32(11):e338–e347.

10. Bayoumi I, Howard M, Holbrook AM, Schabort I. Interventions to im-prove medication reconciliation in primary care. Ann Pharmacother. 2009;43(10):1667–1675.

11. Hot topics in health care transitions of care: the need for a more effective approach to continuing patient care. The Joint Commis-sion website. http://www.jointcommission.org/assets/1/18/hot_top-ics_transitions_of_care.pdf. Accessed November 19, 2014.

12. American Pharmacists Association, American Society of Health-System Pharmacists, Steeb D, Webster L. Improving care transi-tions: optimizing medication reconciliation. J Am Pharm Assoc. 2012;52(4):e43–52. doi: 10.1331/JAPhA.2012.12527.

13. LaMantia MA, Scheunemann LP, Viera AJ, et al. Interventions to improve transitional care between nursing homes and hospitals: a systematic review. J Am Geriatr Soc. 2010;58(4):777–782.

14. Levenson SA, Saffel DA. The consultant pharmacist and the physi-cian in the nursing home: roles, relationships, and a recipe for suc-cess. J Am Med Dir Assoc. 2007;8(1):55–64.

15. Chhabra PT, Rattinger GB, Dutcher SK, et al. Medication recon-ciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm. 2012;8(1):60–75.

16. Martin CM. Avoiding errors during transitions of care: medication reconciliation. Consult Pharm. 2012;27(11):764–769.

17. Crotty M, Rowett D, Spurling L, et al. Does the addition of a phar-macist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, con-trolled trial. Am J Geriatr Pharmacother. 2004;2(4):257–264.

18. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045–1051.

19. Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother. 2006;4(3):236–243.

20. Madden C, Garrett J, Busby-Whitehead J. The interface between nursing homes and emergency departments: a community effort to improve transfer of information. Acad Emerg Med. 1998;5(11):1123–1126.

21. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospi-tal admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840–847.

22. Ambulatory Health Care: 2015 National Patient Safety Goals. The Joint Commission website. http://www.jointcommission.org/as-sets/1/6/2015_NPSG_AHC1.PDF. Accessed November 19, 2014.

23. Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Institute for Healthcare Improvement website. http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed December 2, 2014.

24. World Health Organization. High 5s project: action on patient safety. Assuring medication accuracy at transitions of care: medication rec-onciliation. World Health Organization website. https://www.high5s.org/pub/Manual/AssuringMedicationAccuracyAtTransitionsInCare/

Table 6. Patients’ Bill of Rights during transitions of carePatients and caregivers have the right toBe treated fairly and with respect during care transitions.Care transitions that fit their situation.Know why a care transition is needed.Say what they want and need during care transitions.Take part in planning care transitions for themselves or a loved one.Know costs related to care transitions.Know the people and organizations involved in care transitions.Know the next steps during care transitions.Privacy and access to health care information during care transi-tions.Get help when care transitions do not go well.Source: Reference 46.



CPE informationTo obtain 2.0 contact hours (0.2 CEUs) of CPE credit for this activity, you must complete the online assessment and evaluation. A Statement of Credit will be awarded for a passing grade of 70% or better on the assessment. Pharmacists who successfully complete this activity before March 1, 2018, can receive CPE credit. Your Statement of Credit will be available upon successful completion of the assessment and evaluation and will be stored in your ‘My Training Page’ and on CPE Monitor for future viewing/printing.

CPE instructions:1. Log in or create an account at pharmacist.com and select LEARN from the top of the page; select Continuing Education, then Home Study CPE

to access the Library. 2. Enter the title of this article or the ACPE number to search for the article and click on the title of the article to start the home study. 3. To receive CPE credit, select Enroll Now or Add to Cart from the left navigation and successfully complete the Assessment (with randomized

questions), Learning Evaluation, and Activity Evaluation. 4. To get your Statement of Credit, click “Claim” on the right side of the page. You will need to provide your NABP e-profile ID number to obtain

and print your Statement of Credit. ■ Live step-by-step assistance is available Monday through Friday from 8:30 am to 5:00 pm ET at APhA Member Services at 800-237-APhA

(2742) or by e-mailing [email protected].

Medication_Reconciliation__Assuring_Medication_Accuracy_at_Transitions_in_Care_Standard_Operating_Protocol.pdf. Accessed December 2, 2014.

25. Sullivan C et al. Medication reconciliation in the acute care set-ting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20(2):95–98.

26. Duran-Garcia E, Fernandez-Llamazares CM, Calleja-Hernandez MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm. 2012;34(6):797–802.

27. Bodenheimer T. Coordinating care—a perilous journey through the health system. N Engl J Med. 2008;358(10):1064–1071.

28. Steurbaut S, Leemans L, Leysen T, et al. Medication history recon-ciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010;44(10):1596–1603.

29. Institute for Safe Medication Practices. Keeping track of your medi-cine. ConsumerMedSafety website. http://consumermedsafety.org/tools-and-resources/medication-safety-tools-and-resources/tak-ing-your-medicine-safely/keep-track-of-your-medicine. Accessed December 2, 2014.

30. ISMP list of high-alert medications in community/ambulatory health-care. Institute for Safe Medication Practices website. http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp. Accessed November 18, 2014.

31. ISMP list of high-alert medications in acute care settings. Institute for Safe Medication Practices website. http://www.ismp.org/Tools/institutionalhighAlert.asp. Accessed November 18, 2014.

32. Institute for Healthcare Improvement. Universal medication form. Institute for Healthcare Improvement website. http://www.ihi.org/resources/Pages/Tools/UniversalMedicationForm.aspx. Accessed December 2, 2014.

33. My Medicine List. National Transitions of Care Coalition website. http://www.ntocc.org/Portals/0/PDF/Resources/My_Medicine_List.pdf. Accessed December 2, 2014.

34. U.S. Department of Health and Human Services. How to create a pill card. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/pillcard/pillcard.html. Accessed December 2, 2014.

35. National Transitions of Care Coalition. Elements of excellence in transitions of care (TOC): TOC checklist. National Transitions of Care Coalition website. http://www.ntocc.org/Portals/0/PDF/Re-

sources/TOC_Checklist.pdf. Accessed December 2, 2014. 36. The Care Transitions Program. The Care Transitions Program web-

site. http://www.caretransitions.org/definitions.asp. Accessed De-cember 2, 2014.

37. Revisions to requirements for ambulatory care organizations. The Joint Commission website. http://www.jointcommission.org/as-sets/1/18/JCP0713_Revisions_Req_AHC.pdf. Accessed Novem-ber 19, 2014.

38. Spinewine A, Claeys C, Foulon V, Chevalier P. Approaches for im-proving continuity of care in medication management: a systematic review. Int J Qual Health Care. 2013;25(4):403–417.

39. Huynh C, Wong ICK, Tomlin S. Medication discrepancies at tran-sitions in pediatrics: a review of the literature. Paediatr Drugs. 2013;15(3):203–215.

40. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy. Ann Intern Med. 2013;158(5 Pt 2):397–403.

41. World Health Organization. Assuring medication accuracy at tran-sitions of care. World Health Organization website. http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution6.pdf. Ac-cessed December 10, 2014.

42. Delate T, Chester EA, Stubbings TW, Barnes CA. Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. Pharmacotherapy. 2008;28(4):444–452.

43. Sen S, Bowen JF, Ganetsky VS, et al. Pharmacists implementing transitions of care in inpatient, ambulatory, and community practice settings. Pharm Pract (Granada). 2014;12(2):439.

44. Heyworth L, Clark J, Marcello TB, et al. Aligning medication rec-onciliation and secure messaging: qualitative study of primary care providers’ perspectives. J Med Internet Res. 2013;15(12):e264.

45. Bassi J, Lau F, Bardal S. Use of information technology in medi-cation reconciliation: a scoping review. Ann Pharmacother. 2010;44(5):885–897.

46. National Transitions of Care Coalition. Your rights during transitions of care: A guide for health care consumers and family caregivers. National Transitions of Care Coalition website. http://www.ntocc.org/Portals/0/PDF/Resources/PatientBillOfRights.pdf. Accessed December 2, 2014.



CPE AssessmentInstructions: This exam must be taken online; please see “CPE information” for further instructions. The online system will present these questions in random order to reinforce the learning opportunity. There is only one correct answer to each question.

1. What is the estimated percentage of medication errors that occur during transitions of care? a. 20%b. 40%

c. 60%d. 80%

2. Which of the following contributes to approximately one-half of all hospital-related medication errors?a. Poor communicationb. Prolonged length of stayc. Lack of health insuranced. Undocumented patient allergies

3. Which of the following is an example of a transitions of care model?a. Project BLUE (Better Long-term Utilization Evalua-

tion)b. BOUNCE (Better Outcomes Utilization Necessitating

Care Evaluations) c. H2M (Hospital to Medication)d. BOOST (Better Outcomes for Older Adults through

Safe Transitions)

4. How do you prepare a patient for appropriate transi-tions at hospital discharge to prevent hospital read-mission?a. Perform medication reconciliation after discharge.b. Provide provider-centered education. c. Preemptively schedule outpatient visits.d. Provide discharge instructions to the patient only.

5. Which patient will most likely be at an increased risk for rehospitalization and medication errors?a. 30-year-old patient presenting with anxietyb. 42-year-old patient admitted with hypertensive

urgencyc. 79-year-old patient with dementiad. 66-year-old patient with an involved family support

system

6. What requirement did The Joint Commission add to its National Patient Safety Goal in 2014?a. Maintain an updated provider list. b. Counsel patients on the importance of maintaining

updated medication lists.c. Keep a list of discontinued medication. d. Require patients to share their medication list only

with their primary care provider.

7. Which of the following actions may result in a medi-cation discrepancy?a. Obtaining a complete medical history for the patientb. Using the patient’s home medication when the health

care facility does not have the medication on formu-lary

c. Having a complete prescription history, including OTC and herbal medications

d. Discontinuing a medication because of an acute exac-erbation of a disease state

8. Which is the first step when conducting medication reconciliation, as recommended by The Joint Commis-sion?a. Make clinical decisions as to which medications

should be continued.b. Develop a list of the medications to be prescribed.c. Compare the original and updated medication lists.d. Develop a comprehensive list of all current medica-

tions.

9. Which factor contributes to medication reconciliation errors? a. Young ageb. Multiple medicationsc. Transitions of care at nightd. Short hospital stays

10. Which of the following in an example of a high-alert medication in the ambulatory care setting? a. Acetaminophenb. Lisinopril

c. Levothyroxined. Warfarin

11. Which of the following is an example of a high-alert medication in a long-term care facility?a. Magnesium oxide POb. Nitroprusside I.V.

c. Labetalol I.V.d. Hydralazine I.V.

12. Which is a top barrier to medication reconciliation within a community setting?a. Sufficient staffingb. Time constraintsc. Sufficient break schedulesd. Sufficient access to electronic medical records



13. Which intervention by pharmacists can prevent medi-cation errors during transitions of care?a. Requiring a consultant pharmacist to review medica-

tion profiles dailyb. Following up with patients via telephone calls within

1 year after dischargec. Contacting physicians to resolve any identified medi-

cation discrepanciesd. Reviewing medication profiles only for patients with

documented allergies

14. An optimal interdisciplinary team designed to mini-mize medication discrepancies would contain which of the following?a. Pharmacist, physician, medical residents, social

worker, and nurseb. Pharmacist, medical residents, social worker, and

nursec. Physician, medical residents, pharmacist, physical

therapist, and nursed. Physician, physical therapist, medical residents,

social worker, and pharmacist

15. Which factor may improve transitions of care in the community setting? a. Decreasing the number of community pharmacies

offering transitions of care servicesb. Providing incentives to patients to encourage them to

use transitions of care servicesc. Restricting access to patient medication information

through insurance companiesd. Minimizing reimbursement for transition of care

services provided

16. Which of the following roles remains as the constant during care transitions? a. Pharmacistb. Physician

c. Nursed. Patient

17. According to the Patient’s Bill of Rights during transi-tions of care, patients and caregivers have the right and are encouraged to a. Deny paying for any costs related to care transitions.b. Take part in planning care transitions.c. Falsify medical information to promote faster care.d. Simplify their health care information to minimize

health care costs.

18. Which is a barrier to providing appropriate medica-tion assessment and reconciliation?a. Well-aligned workflowb. Misaligned financial incentives of health care institu-

tionsc. Increased perception of the importance of a medica-

tion listd. High reliability of the health care system

19. Which of the following is an example of transitions of care?a. The movement of patients from the surgical intensive

care unit to the medical intensive care unitb. The movement of patients to a different hospital

room within the general medical floorc. A patient being cared for by multiple providers on

the same medical teamd. A patient living independently who goes to physical

therapy twice weekly

20. Techniques used within the teach-back method when conversing with patients should include which of the following? a. Asking yes/no questions to ensure understandingb. Using medical jargon to get them up to speed on

their medication profilec. Focusing on take-home educational messagesd. Asking the patient to speak only to the pharmacist

about their medications

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