JCAHO Sentinel Event Alert On Medication Errors – Recommendations and Risk Reduction Strategies


Medication errors are a constant challenge for health care providers in maintaining quality of care and risk management. The Joint Commission for Accreditation of Health care Organizations recently issued a Sentinel Event Alert on the importance of medication reconciliation at transition of care as a way to limit medication errors.

JCAHO outlines a 5-step process for medication reconciliation

  1. Develop a list of current medications.
  2. Develop a list of medications to be prescribed
  3. Compare the medications on the two lists.
  4. Make clinical decisions based on the comparison.
  5. Communicate the new list to appropriate caregivers and to the patient.

JCAHO also pulls together reference materials from the medical literature and other sources to provide risk reduction strategies including:

  1. Collect a complete list of current medications (including dose and frequency along with other key information) for each patient on admission.
  2. Reconcile medications within specified time frames (within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, and/or upcoming administration times).
  3. Adopt a standardized form to use for collecting the home medication list and for reconciling the variances (includes both electronic and paper-based forms).
  4. Develop clear policies and procedures for each step in the reconciliation process.

Finally, JCAHO recommends that the health care organization consider:

  1. 1. Placing the medication list in a highly visible location in the patient’s chart and including dosage, drug schedules, immunizations, and allergies or drug intolerances on the list.
  2. Creating a process for reconciling medications at all interfaces of care (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients, and responsible physicians, nurses and pharmacists should be involved in the medication reconciliation process.
  3. On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists and other caregivers.

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