Bm week 7

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Medication Errors During Admission and Discharge: SWOT Analysis of Pharmacist-Led Medication Reconciliation Brittany S. Martin

Herzing University

NU700 Technology Integration and Nursing Informatics: Mindful Health Dr. Crystal Villanueva

June 14, 2026

Medication Errors During Admission and Discharge: SWOT Analysis of Pharmacist-Led Medication Reconciliation

Introduction

Professional nurses play a critical role in implementing quality improvement projects through leadership, care coordination, evidence-based practice, and evaluation of patient outcomes. Nurses are often the first healthcare professionals to identify gaps in care and are essential in translating research findings into practice. Within the Knowledge-to-Action framework, nurses assist in identifying practice problems, adapting evidence-based interventions to local settings, monitoring implementation, and evaluating outcomes. At Mindful Health, improving medication safety is a priority because psychiatric patients frequently receive multiple medications and may transition between inpatient, outpatient, and specialty providers. Therefore, evidence-based interventions that improve medication accuracy and communication are essential.

Practice Problem

Medication errors occurring during admission and discharge represent a significant patient safety concern. Breuker et al. (2021) identified medication discrepancies as common during transitions of care, including medication omissions, duplications, dosing errors, and drug interactions. These errors contribute to adverse drug events, increased healthcare costs, avoidable hospital readmissions, and prolonged treatment. The article found that poor communication and incomplete medication histories were major contributors to discrepancies. The significance of the problem is particularly relevant in psychiatric settings where patients frequently receive multiple psychotropic medications and may receive treatment from several providers.

Evidence-Based Intervention and Rationale

The selected intervention is pharmacist-led medication reconciliation. This intervention involves obtaining a complete medication history, identifying discrepancies, reconciling medication lists, and communicating changes among providers and patients. Research demonstrates that pharmacist-led medication reconciliation reduces medication discrepancies and improves patient safety. At Mindful Health, this intervention is an appropriate choice because many patients receive psychiatric medications in combination with medications prescribed by primary care providers and specialists. Medication reconciliation supports accurate prescribing, improves communication, reduces adverse drug events, and strengthens continuity of care.

SWOT Analysis Table

Strengths: Existing commitment to patient safety; Interdisciplinary collaboration; Established electronic health record system. Weaknesses: Limited access to dedicated pharmacists; Additional workflow requirements; Staff training needs. Opportunities: Reduction in medication discrepancies; Improved patient outcomes and satisfaction; Enhanced quality metrics and compliance. Threats: Financial constraints; Resistance to change; Variable patient participation.

Strengths

The first strength is Mindful Health's commitment to patient safety and quality improvement initiatives. The second strength is the collaborative environment among providers, which facilitates communication regarding medication management. The third strength is the use of an electronic health record system that supports documentation and medication review. Within the Knowledge-to-Action framework, these strengths facilitate adaptation of evidence to practice and support successful implementation.

Weaknesses

A primary weakness is the limited availability of pharmacists in an outpatient psychiatric setting. Another weakness is the additional workflow burden created during implementation. A third weakness involves staff education requirements and the time needed to develop competency with new processes. These weaknesses may slow down implementation and require targeted planning and support.

Opportunities

Implementation provides opportunities to reduce medication discrepancies and improve patient safety. A second opportunity is improvement in patient satisfaction through enhanced communication and medication education. A third opportunity involves strengthening quality metrics, accreditation readiness, and regulatory compliance. These opportunities align with organizational goals and support long-term sustainability.

Threats

Financial limitations may affect the ability to secure pharmacist support and maintain services. Resistance to change among providers and staff may reduce adherence to the intervention. In addition, patient participation may vary because some individuals may not accurately report medications or may have limited engagement in treatment. Addressing these threats requires leadership support, education, and ongoing evaluation.

Conclusion

Medication errors during transitions of care remain a significant patient safety concern. Evidence from Breuker et al. (2021) supports pharmacist-led medication reconciliation as an effective strategy to reduce discrepancies and improve outcomes. At Mindful Health, implementation of this intervention has the potential to improve medication safety, communication, and continuity of care. Conducting a SWOT analysis prior to implementation is valuable because it identifies organizational strengths, weaknesses, opportunities, and threats that may influence project success. Understanding these factors supports strategic planning and increases the likelihood of sustainable practice improvement.

References

Breuker, C., et al. (2021). Medication errors at hospital admission and discharge: Risk factors and impact of medication reconciliation process to improve healthcare.

Herges, J. R., et al. (2021). Impact of pharmacist-led transitions of care interventions on medication-related problems and hospital readmissions. Journal of Patient Safety, 17(8), e1454–e1460.

Mekonnen, A. B., McLachlan, A. J., & Brien, J. A. E. (2016). Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: A systematic review and meta-analysis. BMJ Open, 6(2), e010003.

Tong, E. Y., Roman, C. P., Mitra, B., Yip, G., Gibbs, H., Newnham, H. H., & Galbraith, K. (2017). Reducing medication errors in hospital discharge summaries: A randomized controlled trial. Medical Journal of Australia, 206(1), 36–39.