Think Your Patient Went Home With the Right Dose? Check Again.
The following is based on event reports in the CHPSO database:

Post appendectomy, the patient’s mother wrote down the discharge instructions for administering pain medication to her child. She had the right medication and right time, but the wrong dose. Three days later, the mother rushed her child to the emergency department for constipation and shortness of breath. The child survived.

While it is important for patients and their caregivers to take an active role in their medication management, there are ways providers can help avert medication errors at home. As nurses are often the final point in the medication use process, they play an important role in risk reduction by conveying medication use information to patients. At the minimum, the following information is important:

  • Purpose of medication
  • Name of medication
  • Dosage of medication
  • When to take medication
  • How to take medication
  • How to obtain medication

Also suggested is:

  • Asking patients to maintain an updated medications list that they bring to health care visits
  • Encouraging the use of a single pharmacy for all prescription medications

With these recommendations in mind, researchers conclude that organizations employing a discharge medication plan that recognizes the patient’s co-management role may lead to reduced hospital length of stay as well as reduced readmission rates, particularly for the elderly with multiple medical conditions. Also, the risk of duplicate prescriptions is reduced and identification of harmful drug interactions more likely.


ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305–14.

Institute for Safe Medication Practices Canada. Discharge Medication Reconciliation Checklist. 2011.

North Carolina Department of Health and Human Services. Guidelines for Completing the Medication Administration Clinical Skills Checklist. 2010.

RARE Campaign. Comprehensive Discharge Planning. 2015.

Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000313.

The Pharmacy Profession. American Pharmacist Association. 2015.