Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Errors in medication reconciliation frequently occur at transitions of care. Patients discharged to skilled nursing facilities (SNFs) are particularly vulnerable to the consequences of these mistakes. An interprofessional team at UVA Health implemented a longitudinal quality improvement (QI) project to reduce medication reconciliation errors for patients discharging from acute care medicine services to SNF. [...]

Background: Studies, particularly the MARQUIS trial, have demonstrated the value of pharmacist-led medicine reconciliation. At our institution, we partnered with the College of Pharmacy to implement, revise, and grow a novel hospitalist-led transitions of care pharmacy student rotation. Pharmacy students work directly with attending hospitalists to address admission medication reconciliation errors and collaborate in the [...]

Background: Accurate and reliable medication reconciliation (MedRec) is an indispensable step ensuring patient safety and minimizing medical errors during transitions of care. Yet, it is one of the most challenging aspects in healthcare quality and safety. In fact, inaccurate MedRec accounts for 40 % of medication errors, up to 20% of which result in harm [...]

Background: Medication reconciliation (MR) is a patient medication verification process performed by providers. Best practices and the intricacies of MR are poorly defined nationally, institutionally, and amongst individual providers. In graduate medical education, the skills of MR are implied and imperative in the Transitions of Care (TOC) Milestones 2.0. Prior institutional studies have indicated only [...]

Background: Medication reconciliation (MR) is foundational to patient safety during and after a hospital admission. Although many electronic health records (EHRs) have a dedicated space for documenting home medications on admission, use of such EHR sections remains variable. Providers may opt to record the MR only in the admission H&P, which is not easily updated [...]

Background: Correct home medication histories are critical to prevent harm during a patient’s hospitalization [1]. The wrong dose of a home medication or omission of a medication can result in serious drug toxicity or withdrawal. However, hospital medicine providers and pharmacists may have limited time and resources to perform thorough medication histories for all patients [...]

Case Presentation: A 75-year-old white male presented to the Emergency Department with a 2-day history of gait disturbance, flailing bilateral upper extremity movements, and confusion. His wife stated that his symptoms had been occurring for the past 1 month and acutely worsened over the past several days. For the past year, he had been evaluated [...]