Medication Reconciliation at Care Transitions

A medication list is not necessarily a medication history. The electronic record may contain prescriptions that were stopped months ago, omit medications obtained as samples, or list an inpatient formulary substitute as though it were the patient's usual drug. A transition in care exposes those gaps because one team is handing medication decisions to another. Medication reconciliation is the formal safety process of comparing what the patient is actually taking with what is ordered in the new setting, then ensuring every difference is addressed. It occurs at admission, internal transfer, a change in level of care, and discharge. The goal is not to make two lists look alike. The goal is to prevent an omitted essential drug, a duplicated therapy, a wrong dose, or an outdated inpatient substitution from reaching the patient. A discrepancy is not automatically an error. A prescriber may deliberately hold a medication for surgery, replace an outpatient drug with a formulary alternative, or stop a drug because renal function changed. The danger begins when no one verifies whether the difference was intentional.