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Prescribing discrepancies likely to cause adverse drug events after patient transfer.
Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

Posthospital medication discrepancies are a known safety issue, with the resulting errors stemming from unintended events as well as from the broader transitions in care. Medication reconciliation was named as a 2005 National Patient Safety Goal in part to address these concerns at various transition points in a patient's hospitalization. This study analyzed more than 200 patients' medication records during transitions between acute hospital and their nursing homes to determine the predictive value of medication discrepancies for adverse drug events (ADEs). Investigators found that the drug classes at highest risk for discrepancy-related ADEs were opioid and nonopioid analgesics, providing a specific target for future intervention. A past AHRQ WebM&M commentary discussed the importance of medication reconciliation and barriers to successful adoption, and suggested best practices.

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