Case Presentation:

A 64‐year‐old woman presented with 1 day of worsening dizziness, nausea, and vomiting. She denied abdominal pain, chest pain, or shortness of breath. Past medical history was notable for cerebrovascular disease with TIA, diabetes mellitus, and chronic renal insufficiency Physical examination was unremarkable with the exception of neurologic abnormalities There was dysmetria noted on finger‐to‐nose pointing, and horizontal and vertical nystagmus. At the time of admission, the patient and her husband were unable to provide an up‐to‐date medication list, and the patient was started on a medication regimen based on previous clinic visit notes and discharge summaries. MRI of the head showed multiple new and old frontal, occipital, temporal, medullary, and posterior fossa infarcts. Hospital course was uncomplicated and the patient was discharged on high‐dose lipid‐lowering therapy in addition to home medications after evaluation by cardiology, hospitalist and neurology inpatient teams. The patient was readmitted 11 days later with recurrent stroke. After review of the patient's medications, it was determined that a series of medication errors led to inappropriate dosage of medications poslstroke. At the time of admission, the patient was placed on 25/200 mg of aspirin/dipyridamole once daily, her usual home dose. Current guidelines recommend that for stroke prevention, aspirin/dipyridamole should be dosed twice daily. The primary team did not discuss this dose with the patient's primary care physician and inpatient pharmacy and consulting teams did not note the dose to be inappropriate.


Accurate medication reconciliation is a hospital admission and discharge procedure essential for all internists. When patients transition from the outpatient to inpatient setting, they are particularly vulnerable; this transition often lacks strategically placed redundancies to prevent medication reconciliation errors. It is estimated that approximately 46% of medication errors occur on admission or discharge and an estimated 1 in 5 patient injuries or deaths result from preventable adverse drug events. Successful medication reconciliation requires that all members of the healthcare team have access to patients' home medication lists at The time of admission and discharge, ensuring that medication dosages are appropriate and thai medications are continued and discontinued correctly. The ability of nurses, pharmacists, and patients to serve as independenl checks on key processes may provide a significant opportunity to improve care.


This case highlights the importance of medication reconciliation and how accurate medication reconciliation decreases the opportunity for medication errors and harm.

Author Disclosure:

N. G. Zehnder, none.