Publications

JCAHO Issues Alert on Medication Reconciliation

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has sent an alert to over 15,000 hospitals and health organizations urging them to take specific steps to avoid medication errors to transferred or discharged patients. JCAHO cites the high risk of medication errors for patients who are moving from one location to another and urges "medication reconciliation" whenever a patient is transitioning from one care setting to another.

Without intensified attention to the accuracy of medications given to patients as they move, patients are at risk of injury or death. Last year more than 2,000 reports of medication reconciliation errors were received by United States Pharmacopeia, an independent group that sets standards for drugs and medical products and also has a voluntary medication error reporting program for health care providers.

According to JCAHO, data shows that 63 percent of the reported medication errors that resulted in death or injury were caused by lapses in communication and about half of those would have been avoided through effective medication reconciliation.

To reduce the risk of errors related to medication reconciliation, the alert recommends that health care organizations:

  • Put the list of medications in a highly visible place in patient charts and include essential information about dosages, drug schedules, immunizations and drug allergies.
  • Reconcile medications at each interface of care, specifically including admission, transfer and discharge. The patient and responsible physicians, nurses and pharmacists should be involved in this process.
  • Provide each patient with a complete list of medications that he or she will take after being discharged from the facility, as well as instructions on how and how long to take any new medications. The patient should be encouraged to carry this list and share it with any caregivers who provide follow-up care.


Print Version