On admission the medication list is both the most useful and the most error-prone document you hold. Reconcile it actively: confirm what the patient actually takes against what is recorded, and read the list against the admitting problem.
The harm usually comes from a drug already on the list — a continued nephrotoxic agent in acute kidney injury, a missed anticoagulant, a duplicated sedative — rather than a newly started one. Repeat the exercise at discharge, when the list has changed the most.
- Reconcile the recorded list against what the patient actually takes, including over-the-counter and herbal products.
- Read each drug against the admitting problem and hold what the acute illness makes unsafe.
- Flag anticoagulants, insulin, opioids and nephrotoxics explicitly at admission.
- Reconcile again at discharge, when the medication list has changed most.
Why it matters
The drug that harms an inpatient is usually one already on the list, not one newly started.
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