At each admission, transfer and discharge, build the medication list from more than one source, the patient or carer, the dispensing record and the previous note, because any single source is often incomplete. Reconcile it against what is actually being prescribed, and flag discrepancies before they propagate.
Pay particular attention to high-risk drugs (anticoagulants, insulin and other hypoglycaemics, opioids, immunosuppressants) and to medicines that were started for a short course but never stopped. Record the reason for every change so the next clinician is not left guessing, and give the patient an updated list they understand.
- Build the medication list from at least two sources at every transition of care.
- Check high-risk drugs first: anticoagulants, insulin, opioids, immunosuppressants.
- Look for short-course medicines that were never stopped.
- Record the reason for each change and give the patient an updated list.
Why it matters
Most avoidable medication harm begins with an inaccurate list carried across a transition of care.
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