Medication Reconciliation Failures: Negligence During Hospital Discharge

What Is Medication Reconciliation?

Medication reconciliation is the formal process of creating the most accurate possible list of all medications a patient is taking — including drug name, dose, route, and frequency — and comparing that list against the patient's medication orders at every transition of care. The goal is to prevent medication errors such as omissions, duplications, dosing errors, and drug interactions.

The Joint Commission requires medication reconciliation at every transition of care:

1. Admission — Comparing the patient's home medication list to admission orders
2. Transfer — Comparing medications when moving between units (e.g., ICU to medical floor)
3. Discharge — Comparing hospital medications to the discharge medication list

Despite being a mandatory patient safety process, medication reconciliation failures remain one of the most common sources of preventable patient harm. The Institute for Healthcare Improvement (IHI) estimates that 60% of medication errors occur during transitions of care.

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How Medication Reconciliation Fails

Incomplete Medication History

The reconciliation process begins with obtaining an accurate medication history. This often fails because:

• Patient is a poor historian — The patient is confused, cognitively impaired, or simply doesn't know their medications
• No family member available — There is no caregiver to provide the medication list
• Multiple prescribers — The patient sees multiple physicians who don't coordinate care
• Over-the-counter and herbal medications omitted — These can interact with prescribed medications
• Source of information is unreliable — The medication list is obtained from an outdated EHR rather than the patient's actual pill bottles

Admission Reconciliation Errors

During admission, failures include:

• Failing to continue a home medication — The patient's chronic medications (e.g., anticoagulants, anti-seizure medications, immunosuppressants) are not continued during hospitalization
• Duplicate therapy — A medication is ordered that duplicates a home medication the patient is already taking, leading to double-dosing
• Wrong dose — The hospital uses a different concentration or formulation without adjusting the dose

Discharge Reconciliation Errors

Discharge is the most dangerous transition because the patient is going from a controlled hospital environment to self-management. Common discharge reconciliation errors include:

• Omitting a new medication — A medication started during hospitalization is not included on the discharge list
• Failing to discontinue a hospital-only medication — A medication that was started for an acute issue (e.g., a proton pump inhibitor for stress ulcer prophylaxis) is inadvertently continued at discharge
• Duplicate therapy — Two medications in the same class are prescribed (e.g., two ACE inhibitors)
• Wrong dose at discharge — The dose is not adjusted for the transition from IV to oral formulation, or the dose is based on an outdated weight
• Failing to reconcile warfarin/anticoagulants — Discharging a patient on warfarin without clear instructions, bridge therapy, or follow-up INR monitoring
• Insulin discharge errors — Discharging a patient on insulin without proper dosing instructions, blood glucose monitoring supplies, or follow-up

Transfer Reconciliation Errors

When patients move between hospital units:

• ICU to floor — Medications appropriate for ICU (e.g., IV vasopressors, sedation) may not be discontinued when the patient transfers
• Floor to ICU — Home medications that were held may not be restarted

The Standard of Care for Medication Reconciliation

Joint Commission Requirements

The Joint Commission's National Patient Safety Goal (NPSG) on medication reconciliation requires hospitals to:

1. Obtain and document a complete medication list on admission
2. Compare the medication list to new medications ordered
3. Communicate the medication list to the next provider of care at discharge
4. Provide the patient with written instructions at discharge, including the medication list

New York State Requirements

Under 10 NYCRR § 405 and PHL § 2805-j, New York hospitals must implement patient safety programs that address medication reconciliation. Failure to comply can be evidence of negligence.

ISMP Best Practices

The ISMP recommends:

• Pharmacist involvement — Pharmacists should participate in medication reconciliation, particularly for high-risk patients
• Patient involvement — Patients should be given a written medication list and instructed to carry it at all times
• Follow-up — A follow-up call or visit should be made within 48-72 hours of discharge to verify medication understanding

Proving Negligence in Reconciliation Cases

Medical Record Review

The key evidence in a medication reconciliation case includes:

• Admission medication history — Was a complete history obtained and documented?
• Admission orders — Were home medications continued, modified, or discontinued?
• Discharge summary — Does it include a complete medication list with instructions?
• Discharge prescription list — Does it match the discharge summary?
• Follow-up documentation — Was follow-up arranged and documented?

Causation

Proving causation in reconciliation cases requires showing that the reconciliation failure directly caused the patient's injury. For example:

• A patient's anticoagulant was omitted at discharge, and the patient suffered a stroke
• A patient was discharged on duplicate diuretics, and suffered severe dehydration and kidney injury
• A patient's anti-seizure medication was not continued at discharge, and the patient suffered a seizure

Expert Testimony

Medication reconciliation cases typically require:

• A physician expert to testify about the medical consequences of the reconciliation failure
• A pharmacy expert to testify about reconciliation standards and pharmacy involvement
• A nursing expert to testify about discharge education and nursing standards

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Damages and Legal Rights

Compensable Damages

New York does not cap medical malpractice damages. Compensation may include:

• Readmission costs — Medical expenses from treating the adverse drug event caused by the reconciliation failure
• Additional medical treatment — Costs of treating complications (e.g., stroke, kidney injury, seizure)
• Lost wages — Past and future
• Pain and suffering
• Loss of consortium
• Wrongful death damages under EPTL § 5-4.1

Statute of Limitations

Under CPLR § 214-a, the statute of limitations is 2.5 years from the date of the error (or end of continuous treatment). For municipal hospitals, a Notice of Claim must be filed within 90 days.

Frequently Asked Questions

What is medication reconciliation?

Medication reconciliation is the process of comparing a patient's medication orders to all medications the patient has been taking, at every transition of care — admission, transfer, and discharge. The goal is to prevent omissions, duplications, and interactions.

When do medication reconciliation errors most commonly occur?

The most dangerous reconciliation errors occur at discharge, when the patient transitions from a controlled hospital environment to self-management. Admission reconciliation errors are also common, particularly when the patient cannot provide an accurate medication history.

Can I sue the hospital for a medication reconciliation error?

Yes. Hospitals are responsible for implementing and maintaining medication reconciliation processes. If a reconciliation failure caused harm, the hospital and individual providers (physicians, pharmacists, nurses) can be held liable.

What is the Joint Commission's role in medication reconciliation?

The Joint Commission requires medication reconciliation as a National Patient Safety Goal. Hospitals must obtain a complete medication list, compare it to new orders, communicate it to the next provider, and provide the patient with written discharge instructions.

How is a medication reconciliation case investigated?

The medical record is reviewed for the admission medication history, admission orders, discharge summary, discharge prescriptions, and follow-up documentation. Expert witnesses (physician, pharmacist, nurse) review the records and testify about the standard of care.

How long do I have to file a medication reconciliation lawsuit in NY?

Generally 2.5 years under CPLR § 214-a. For municipal hospitals, a Notice of Claim must be filed within 90 days and the SOL is 1 year and 90 days.

This article is for informational purposes only and does not constitute legal advice. Prior results do not guarantee a similar outcome. No attorney-client relationship is created by reading this article or contacting MDLaw Firm.