---as documented in this recent paper. Important meds, like antiplatelet agents and statins. And it was even worse if the patient was in the ICU.
The study period was 1997 to 2009. Although systems initiatives (computer generated med lists, collaboration with the hospital pharmacy) to help improve discharge medication instructions were well in place by 1997 med rec as we now know it was not introduced until 2005. These processes all required someone to pick and choose from an array of medications followed by computer generation of a list for the patient. Good intentions, the systematization of the process, added steps to the old method of ordering “patient to continue meds per previous home routine with the following changes:...” Those added steps complicated the loop and created opportunities for error.