Accreditation

Sentinel Event Alert stresses medication reconciliation efforts

Briefings on The Joint Commission, March 1, 2006

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The JCAHO on January 25 issued a Sentinel Event Alert urging hospitals to increase medication reconciliation efforts during transitions of care, citing the increased risk of injury or death due to errors in these situations.

Reconciliation should occur whenever a patient moves from one location to another within a facility or from one practitioner to another, the JCAHO alert said. Otherwise, the patient could receive duplicate medications, wrong doses, or wrong dosage forms.

"Accurate and complete medication reconciliation can prevent numerous prescribing and administration errors," the JCAHO said in the alert. "This means medication reconciliation applies to all care settings-including ambulatory, emergency and urgent care, long-term care, and home care-as well as inpatient services."

According to the JCAHO, medication reconciliation consists of the following five steps:

  • Create a list of current medications for the patient
  • Create a list of medications to be prescribed to the patient
  • Compare the medications on the two lists
  • Make clinical decisions based on the two lists
  • Communicate the new list to the correct caregivers and the patient

    Medications include prescriptions, over-the-counter drugs, vitamins, herbals, and nutraceuticals, the JCAHO said.

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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