Hospitals have long been concerned about medication errors during the flow of in patient care. Until recently, however, relatively little attention has been paid to the problem of errors at the points of transition between in patient and out patient care. Many hospitalized patients are on a large number of chronic medications. The transition points at admission and discharge are especially vulnerable for such patients because of the need to communicate and document complex medication history. At admission the patient may provide faulty or fragmentary information. At discharge the patient may not understand the doctor’s instructions. Hospitalization often results in one or more changes in the patient’s chronic medication. When medication orders are written in the hospital and when the patient is instructed at discharge these orders and instructions must take into account the patient’s pre-hospital medications and dosages. This is what the Joint Commission on Accreditation of Healthcare Organizations in its 2005 patient safety initiatives terms reconciliation of medications across the continuum of care. This issue was reviewed in an article and an accompanying editorial in the current issue of the American Journal of Health-system Pharmacy. (Open access until September 1 05).
It’s good to see this issue getting the attention it deserves. Accurate transfer of information at the transition of care seems to be an elusive quality goal. Deficiencies in the process are what we hospitalists often refer to as the “information voltage drop.”