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  • Publication # 13-RA008

From the Director

From the Director

Image of AHRQ's Director Dr. Clancy  While it may be axiomatic that clinicians need to know their patients’ medi-cations, in reality, this information is often unavailable when important treatment decisions are made, especially at key transition points—hospital admission, transfer between care settings, and discharge. 

AHRQ’s report Making Health Care Safer II, which was posted on the AHRQ Web site in March 2013, cites published articles suggesting that 40 to 50 percent of patients experience unintentional medication discrepancies upon admission to acute care hospitals, slightly higher rates of unintentional discrepancies during internal hospital transfers, and at least 40 percent of patients experience discrepancies at hospital discharge ( 

A recent example shows how easily drug errors can happen, according to a case posted on AHRQ’s Web M&M (morbidity and mortality rounds) site

A 90-year-old woman was brought to a hospital emergency department (ED) after breaking her hip. The woman’s daughter gave a nurse her mother’s medication bottles, including one for high blood pressure. Using that information, the nurse prepared a list of drugs for the woman’s hospital stay. Before the woman had hip surgery, a physician noticed her blood pressure was too high and increased her blood pressure medicine from 75 mg to 100 mg. Shortly before surgery, the woman went into cardiac arrest. She was successfully resuscitated, but her surgery had to be postponed. Only when the woman was moved to the intensive care unit did another nurse notice that the dose level of the blood pressure medicine brought from the patient’s home was actually 25 mg, not 75 mg. Fortunately, the woman recovered and several days later had the surgery. 

After identifying the error, the hospital staff fixed the mistake, apologized to the patient, and launched a review to find out how similar mistakes could be prevented in the future. More hospitals are working to reduce the chance of drug-related injuries by using a process known as medication reconciliation. This involves comparing a patient’s current drug routine to any changes a physician makes when a patient is admitted, transferred, or released from the hospital.

In the case of the 90-year-old patient’s blood pressure drug, careful medication reconciliation in the ED would have verified the proper dosage of blood pressure medicine the patient was taking and would have prevented her later cardiac arrest. To help hospitals with this process, AHRQ funded research for a new toolkit based on a successful program at Northwestern Memorial Hospital in Chicago. Known as MATCH (Medications at Transitions and Clinical Handoffs), the toolkit provides a step-by-step method so hospitals can review and improve current processes or create new ones. 

The cover story in this issue tells how MATCH is helping hospitals with medication reconciliation. We expect MATCH to make medication reconciliation simpler, easier, and more effective.

Carolyn Clancy, M.D.

Page last reviewed May 2013
Internet Citation: From the Director: From the Director. May 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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