KTA Part 3

1

Reducing Medication Errors through Medication Reconciliation at Admission and Discharge

Name

School

Course

Professor

Date

Reducing Medication Errors through Medication Reconciliation at Admission and Discharge

Professional nurses are strategically positioned to identify practice problems because they work at the point where patient needs, care processes, and clinical outcomes intersect. In everyday practice, nurses detect gaps in safety and quality through medication administration, admission assessment, discharge planning, incident review, and participation in quality improvement activities. Evidence from the literature allows nurses to move beyond recognizing a problem to selecting and implementing interventions that are credible, measurable, and relevant to practice. One persistent problem observed during transitions of care is medication discrepancy at hospital admission and discharge, when incomplete medication histories, inconsistent documentation, and communication failures can lead to preventable medication errors. This paper examines that practice problem using Breuker et al. (2021) as the original source article and argues that a standardized interdisciplinary medication reconciliation process with strong nursing involvement is the most appropriate evidence-based intervention for an acute care medical-surgical setting.

Practice Problem

Breuker et al. (2021) identified unintended medication discrepancies at admission and discharge as a significant patient safety problem in hospitalized adults. In their prospective observational study of 904 patients, 29.4% experienced at least one unintended medication discrepancy across these transitions. Of those discrepancies, 98.2% were classified as medication errors, demonstrating that the problem extends well beyond minor documentation inconsistencies. Omissions were the most common error type, accounting for 59.3% of cases. The seriousness of the problem is further underscored by the authors’ finding that 36% of the errors were serious or very serious and that nearly 40% had the potential for moderate clinical impact. The study also identified polypharmacy as a major risk factor, with error rates increasing as the number of medications increased.

The significance of this problem is substantial for both patients and healthcare systems. Medication discrepancies at transition points can contribute to adverse drug events, treatment delays, avoidable readmissions, prolonged hospitalization, and increased cost. Breuker et al. (2021) demonstrate that these events are common rather than exceptional, particularly in patients with complex medication regimens. Their findings make clear that medication reconciliation is not simply a regulatory documentation requirement; it is a high-value safety process that requires sustained attention from clinicians. Because nurses routinely obtain histories, compare medication lists, administer medications, communicate with prescribers and pharmacists, and reinforce discharge teaching, the problem is especially relevant to nursing practice.

Literature Review: Standardized Interdisciplinary Medication Reconciliation with Strong Nursing Involvement

Recent literature supports one intervention as the best fit for practice: a standardized interdisciplinary medication reconciliation process with strong nursing involvement at admission and discharge. Rather than relying on informal medication review, this intervention uses a structured workflow for obtaining the best possible medication history, reconciling medications in the electronic health record, clarifying discrepancies with pharmacists and prescribers, educating patients and families, and monitoring compliance through audits or feedback. Across the literature, the most effective versions of this intervention share the same core features—standardization, role clarity, interdisciplinary communication, and accountability.

The first major theme in literature is that standardization reduces discrepancy rates and improves completion of reconciliation tasks. In a multicenter quality improvement project across 18 hospitals, Alghamdi et al. (2023) implemented standardized medication reconciliation protocols, interdisciplinary workflows, documentation expectations, and improvement cycles. The project reduced the percentage of patients with at least one outstanding unintentional discrepancy from 27% to 7% at admission and from 17% to 5% at discharge, while also improving documentation compliance within 24 hours. Similarly, Xu et al. (2025) reported that when an interdisciplinary team introduced a standardized admission medication reconciliation workflow, targeted education, and feedback in post-acute care facilities, completion rates improved from 13% to 87% in one unit and from 51% to 82% in another. Together, these studies show that reliable structures, not individual vigilance alone, are central to safer transitions of care.

A second theme is that nursing involvement is not peripheral to reconciliation success; it is one of the mechanisms by which the intervention works. Han et al. (2024) describes nurse-led medication management during transitional care as a critical component in preventing drug-related problems. Their review highlights nursing responsibilities in information collection and evaluation, communication and education, support for medication adherence, and coordination among healthcare professionals. This perspective is important because it helps explain why reconciliation improves outcomes when nurses are deliberately integrated into the process. Nurses are often the clinicians with the most sustained patient contact during admission, hospitalization, and discharge, which places them in a strong position to identify inconsistencies, reinforce education, and recognize barriers such as low health literacy, regimen complexity, or medication access problems.

A third theme is implementation feasibility. The evidence suggests that a nurse-integrated reconciliation process can be incorporated into routine practice without depending exclusively on additional pharmacy staffing. Xu et al. (2025) found improvement through workflow redesign, EHR optimization, provider education, and feedback rather than through expansion of pharmacy resources. Alghamdi et al. (2023) likewise demonstrated that large-scale improvement was possible across diverse hospitals when roles, measures, and accountability structures were clarified. In practical terms, literature supports an intervention that can be adapted to real clinical environments: nurses can lead medication history collection, discrepancy identification, and discharge teaching; pharmacists can focus on complex review and high-risk cases; and prescribers can make final decisions and order corrections. Synthesized across the three studies, the evidence indicates that the strongest intervention is not a single isolated task, but a coordinated, standardized reconciliation process in which nursing participation is explicit and central.

Why This Is the Best Evidence-Based Intervention for My Clinical Practice Setting

For an acute care medical-surgical setting, this intervention is the best evidence-based choice because it aligns closely with how care is actually delivered. Nurses provide continuous bedside coverage and are present at the exact moments when discrepancies are most likely to surface, during admission assessment, medication administration, patient teaching, and discharge preparation. A standardized reconciliation process supports nurses in these responsibilities by giving them a clear workflow and defined expectations rather than leaving safety to variable individual practice.

This intervention is also realistic and sustainable. It builds on resources already present in most hospital settings by clarifying who does what: nurses collect and verify medication information, identify discrepancies, and provide patient education; pharmacists review complex regimens and high-risk concerns; and prescribers resolve discrepancies through order decisions. That role differentiation is especially valuable in settings with high admission and discharge volumes, where medication errors are more likely if responsibilities are ambiguous. The intervention directly addresses the polypharmacy-related risk identified by Breuker et al. (2021) and offers measurable outcomes, such as discrepancy rates, reconciliation completion rates, documentation compliance, and safety event trends.

Finally, this intervention fits the Knowledge-to-Action approach because it translates a clearly identified knowledge-practice gap into a feasible change process. The evidence does not merely confirm that discrepancies exist; it shows how organizations can reduce them through education, workflow redesign, interdisciplinary coordination, and ongoing monitoring. In that sense, the intervention is both evidence based and practice ready.

Conclusion

Medication discrepancies at hospital admission and discharge represent a prevalent and clinically meaningful practice problem. Breuker et al. (2021) establish the seriousness of the issue by showing that nearly one-third of hospitalized patients experienced at least one unintended discrepancy and that many of those errors carried the potential for significant harm. Current evidence supports a standardized interdisciplinary medication reconciliation process with strong nursing involvement as the most appropriate intervention for reducing this risk. The literature shows that medication reconciliation is most effective when it is structured, team based, and reinforced through education, role clarity, EHR support, and accountability measures. For nursing, the problem is especially important because nurses are central to assessment, communication, patient education, and continuity across transitions of care. Using evidence from the literature to guide practice changes strengthens patient safety, improves care coordination, and demonstrates the value of professional nursing judgment in addressing real clinical problems.

References

Alghamdi, D. S., Alhrasen, M., Kassem, A., Alwagdani, A., Tourkmani, A. M., Alnowaiser, N., Al Barakah, Y., & Alotaibi, Y. K. (2023). Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: A multicentre study. BMJ Open Quality, 12(2), e002121. https://doi.org/10.1136/bmjoq-2022-002121

Breuker, C., Macioce, V., Mura, T., Castet-Nicolas, A., Audurier, Y., Boegner, C., & Sultan, A. (2021). Medication errors at hospital admission and discharge: Risk factors and impact of medication reconciliation process to improve healthcare. Journal of Patient Safety, 17(7), e645-e652. https://doi.org/10.1097/PTS.0000000000000420

Han, Y., Chen, J., Xu, Y., Huang, P., & Hou, L. (2024). Nurse-led medication management as a critical component of transitional care for preventing drug-related problems. Aging Clinical and Experimental Research, 36, 151. https://doi.org/10.1007/s40520-024-02799-3

Xu, K., Renzi, N., & Ragusa, L. (2025). Iterative interventions to improve admission medication reconciliation completion rates and reduce medication errors at post-acute care facilities. Patient Safety, 7(2). https://doi.org/10.33940/001c.134045

1

Reducing Medication Errors through Medication Reconciliation at Admission and Discharge

Name

School

Course

Professor

Date

Reducing Medication Errors through Medication Reconciliation at Admission and Discharge

Professional nurses are strategically positioned to identify practice problems because they work at the point where patient needs, care processes, and clinical outcomes intersect. In everyday practice, nurses detect gaps in safety and quality through medication administration, admission assessment, discharge planning, incident review, and participation in quality improvement activities. Evidence from the literature allows nurses to move beyond recognizing a problem to selecting and implementing interventions that are credible, measurable, and relevant to practice. One persistent problem observed during transitions of care is medication discrepancy at hospital admission and discharge, when incomplete medication histories, inconsistent documentation, and communication failures can lead to preventable medication errors. This paper examines that practice problem using Breuker et al. (2021) as the original source article and argues that a standardized interdisciplinary medication reconciliation process with strong nursing involvement is the most appropriate evidence-based intervention for an acute care medical-surgical setting.

Practice Problem

Breuker et al. (2021) identified unintended medication discrepancies at admission and discharge as a significant patient safety problem in hospitalized adults. In their prospective observational study of 904 patients, 29.4% experienced at least one unintended medication discrepancy across these transitions. Of those discrepancies, 98.2% were classified as medication errors, demonstrating that the problem extends well beyond minor documentation inconsistencies. Omissions were the most common error type, accounting for 59.3% of cases. The seriousness of the problem is further underscored by the authors’ finding that 36% of the errors were serious or very serious and that nearly 40% had the potential for moderate clinical impact. The study also identified polypharmacy as a major risk factor, with error rates increasing as the number of medications increased.

The significance of this problem is substantial for both patients and healthcare systems. Medication discrepancies at transition points can contribute to adverse drug events, treatment delays, avoidable readmissions, prolonged hospitalization, and increased cost. Breuker et al. (2021) demonstrate that these events are common rather than exceptional, particularly in patients with complex medication regimens. Their findings make clear that medication reconciliation is not simply a regulatory documentation requirement; it is a high-value safety process that requires sustained attention from clinicians. Because nurses routinely obtain histories, compare medication lists, administer medications, communicate with prescribers and pharmacists, and reinforce discharge teaching, the problem is especially relevant to nursing practice.

Literature Review: Standardized Interdisciplinary Medication Reconciliation with Strong Nursing Involvement

Recent literature supports one intervention as the best fit for practice: a standardized interdisciplinary medication reconciliation process with strong nursing involvement at admission and discharge. Rather than relying on informal medication review, this intervention uses a structured workflow for obtaining the best possible medication history, reconciling medications in the electronic health record, clarifying discrepancies with pharmacists and prescribers, educating patients and families, and monitoring compliance through audits or feedback. Across the literature, the most effective versions of this intervention share the same core features—standardization, role clarity, interdisciplinary communication, and accountability.

The first major theme in literature is that standardization reduces discrepancy rates and improves completion of reconciliation tasks. In a multicenter quality improvement project across 18 hospitals, Alghamdi et al. (2023) implemented standardized medication reconciliation protocols, interdisciplinary workflows, documentation expectations, and improvement cycles. The project reduced the percentage of patients with at least one outstanding unintentional discrepancy from 27% to 7% at admission and from 17% to 5% at discharge, while also improving documentation compliance within 24 hours. Similarly, Xu et al. (2025) reported that when an interdisciplinary team introduced a standardized admission medication reconciliation workflow, targeted education, and feedback in post-acute care facilities, completion rates improved from 13% to 87% in one unit and from 51% to 82% in another. Together, these studies show that reliable structures, not individual vigilance alone, are central to safer transitions of care.

A second theme is that nursing involvement is not peripheral to reconciliation success; it is one of the mechanisms by which the intervention works. Han et al. (2024) describes nurse-led medication management during transitional care as a critical component in preventing drug-related problems. Their review highlights nursing responsibilities in information collection and evaluation, communication and education, support for medication adherence, and coordination among healthcare professionals. This perspective is important because it helps explain why reconciliation improves outcomes when nurses are deliberately integrated into the process. Nurses are often the clinicians with the most sustained patient contact during admission, hospitalization, and discharge, which places them in a strong position to identify inconsistencies, reinforce education, and recognize barriers such as low health literacy, regimen complexity, or medication access problems.

A third theme is implementation feasibility. The evidence suggests that a nurse-integrated reconciliation process can be incorporated into routine practice without depending exclusively on additional pharmacy staffing. Xu et al. (2025) found improvement through workflow redesign, EHR optimization, provider education, and feedback rather than through expansion of pharmacy resources. Alghamdi et al. (2023) likewise demonstrated that large-scale improvement was possible across diverse hospitals when roles, measures, and accountability structures were clarified. In practical terms, literature supports an intervention that can be adapted to real clinical environments: nurses can lead medication history collection, discrepancy identification, and discharge teaching; pharmacists can focus on complex review and high-risk cases; and prescribers can make final decisions and order corrections. Synthesized across the three studies, the evidence indicates that the strongest intervention is not a single isolated task, but a coordinated, standardized reconciliation process in which nursing participation is explicit and central.

Why This Is the Best Evidence-Based Intervention for My Clinical Practice Setting

For an acute care medical-surgical setting, this intervention is the best evidence-based choice because it aligns closely with how care is actually delivered. Nurses provide continuous bedside coverage and are present at the exact moments when discrepancies are most likely to surface, during admission assessment, medication administration, patient teaching, and discharge preparation. A standardized reconciliation process supports nurses in these responsibilities by giving them a clear workflow and defined expectations rather than leaving safety to variable individual practice.

This intervention is also realistic and sustainable. It builds on resources already present in most hospital settings by clarifying who does what: nurses collect and verify medication information, identify discrepancies, and provide patient education; pharmacists review complex regimens and high-risk concerns; and prescribers resolve discrepancies through order decisions. That role differentiation is especially valuable in settings with high admission and discharge volumes, where medication errors are more likely if responsibilities are ambiguous. The intervention directly addresses the polypharmacy-related risk identified by Breuker et al. (2021) and offers measurable outcomes, such as discrepancy rates, reconciliation completion rates, documentation compliance, and safety event trends.

Finally, this intervention fits the Knowledge-to-Action approach because it translates a clearly identified knowledge-practice gap into a feasible change process. The evidence does not merely confirm that discrepancies exist; it shows how organizations can reduce them through education, workflow redesign, interdisciplinary coordination, and ongoing monitoring. In that sense, the intervention is both evidence based and practice ready.

Conclusion

Medication discrepancies at hospital admission and discharge represent a prevalent and clinically meaningful practice problem. Breuker et al. (2021) establish the seriousness of the issue by showing that nearly one-third of hospitalized patients experienced at least one unintended discrepancy and that many of those errors carried the potential for significant harm. Current evidence supports a standardized interdisciplinary medication reconciliation process with strong nursing involvement as the most appropriate intervention for reducing this risk. The literature shows that medication reconciliation is most effective when it is structured, team based, and reinforced through education, role clarity, EHR support, and accountability measures. For nursing, the problem is especially important because nurses are central to assessment, communication, patient education, and continuity across transitions of care. Using evidence from the literature to guide practice changes strengthens patient safety, improves care coordination, and demonstrates the value of professional nursing judgment in addressing real clinical problems.

References

Alghamdi, D. S., Alhrasen, M., Kassem, A., Alwagdani, A., Tourkmani, A. M., Alnowaiser, N., Al Barakah, Y., & Alotaibi, Y. K. (2023). Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: A multicentre study. BMJ Open Quality, 12(2), e002121. https://doi.org/10.1136/bmjoq-2022-002121

Breuker, C., Macioce, V., Mura, T., Castet-Nicolas, A., Audurier, Y., Boegner, C., & Sultan, A. (2021). Medication errors at hospital admission and discharge: Risk factors and impact of medication reconciliation process to improve healthcare. Journal of Patient Safety, 17(7), e645-e652. https://doi.org/10.1097/PTS.0000000000000420

Han, Y., Chen, J., Xu, Y., Huang, P., & Hou, L. (2024). Nurse-led medication management as a critical component of transitional care for preventing drug-related problems. Aging Clinical and Experimental Research, 36, 151. https://doi.org/10.1007/s40520-024-02799-3

Xu, K., Renzi, N., & Ragusa, L. (2025). Iterative interventions to improve admission medication reconciliation completion rates and reduce medication errors at post-acute care facilities. Patient Safety, 7(2). https://doi.org/10.33940/001c.134045