JCAHO issues alert on meds at hand-off

The Joint Commission on Accreditation of Healthcare Organizations has issued a new Sentinel Event Alert that urges special attention to the accuracy of medications given to patients as they transition from one care setting to another, or one practitioner to another. The failure to reconcile medications during these patient hand-offs can cause serious patient injuries and even death, the Joint Commission warns.

According to the Alert, medication reconciliation should occur whenever a patient moves from one location to another location in a health care facility (for example, from a critical care unit to a general medical unit); or from one health care facility to another or to home; and/or when there is a change in the caregivers responsible for the patient. (See the full Alert at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm.)

To reduce the risk of errors related to medication reconciliation, the Alert recommends that risk managers ensure these steps are taken:

  • Put the list of medications in a highly visible place in the patient's chart and include essential information about dosages, drug schedules, immunizations, and drug allergies. Reconcile medications at each interface of care, specifically including admission, transfer, and discharge. The patient and responsible physicians, nurses, and pharmacists should be involved in this process.
  • Provide each patient with a complete list of medications that he or she will take after being discharged from the facility, as well as instructions on how and how long to take any new medications. The patient should be encouraged to carry this list and share it with any caregivers who provide any follow-up care.