Don’t prescribe patients medications at discharge that they were on prior to admission without verifying that these medications are still needed and that the discharge medications will not result in duplication, drug interactions, or adverse events.

Rationale and Comments

Treatments and procedures during a hospitalization may impact a patient’s ongoing need for a medication they were receiving prior to admission. Care should be taken at discharge to consider each medication taken prior to hospitalization in light of the patient’s current state. Unnecessary medications should be discontinued, duplicate or overlapping therapies should be changed, and the specific changes should be clearly communicated to the patient. The Joint Commission recommends a thorough medication review at admission and discharge to prevent any unnecessary medications being continued.

Sponsoring Organizations

American Society of Health-System Pharmacists

Sources

Expert consensus

Disciplines

Geriatric Medicine

References

Varkey, P, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm. 2007; 64:850-5.
Najafzadeh M, et al. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Am J Manag Care 2016; 22:654-61.
Lehnbom, EC, et al. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014; 48:1298-1312.
The Joint Commission. 2017 National Patient Safety Goals [Internet; cited 2017 Jan 21]. Available from: www.jointcommission.org/standards_information/npsgs.aspx.