SDS Accreditation Update

JCAHO tips to avoid medication errors

The most recent Sentinel Event Alert issued by the Joint Commission on the Accreditation of Healthcare Organizations addresses medication reconciliation and the importance of this process in reducing the risk of medication errors.

To reduce errors related to medication reconciliation, the Alert authors’ recommendations include1:

  • putting 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;
  • reconciling 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;
  • providing 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;
  • developing clear policies and procedures for each step in the reconciliation process.

As part of its current National Patient Safety Goals, the Joint Commission also requires that each accredited health care organization1:

  • implement a process for obtaining and documenting a complete list of the patient’s current medications upon admission. This process includes a comparison of the medications the organization provides to those on the list. The patient should be asked to describe or confirm any prescription medications, over-the-counter medications, vitamins, herbs, or other supplements that he or she takes;
  • communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.


  1. Joint Commission on the Accreditation of Healthcare Organizations. Using medication reconciliation to prevent errors. Sentinel Event ALERT 2006; 35.