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Medication Reconciliation Across Care Transitions: Where Errors Actually Happen

  • 78 minutes
  • 41 slides
What we'll cover
  • 0:00 Why Lists Fail Patients
  • 7:00 Highest-Risk Transition Points
  • 17:00 Where Histories Go Wrong
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What you'll take away

Practical shifts you can apply this week

  • Identify High-Risk Transition Points

    See where clinically meaningful discrepancies most often begin, from admission to discharge and post-acute handoff.

  • Compare Distinct Error Patterns

    Differentiate how histories, list upkeep, ordering, and discharge communication fail in different ways.

  • Diagnose Predictable Failure Factors

    Spot the system and human conditions that make reconciliation failures more likely in high-risk patients.

  • Evaluate Measures That Matter

    Use process and outcome measures that reflect real medication risk, not just completed fields in the EHR.

  • Design One Practical Improvement Plan

    Leave with a focused plan for one vulnerable transition in your setting, built around real cases.

Agenda

What we'll cover

  1. 0:00

    Why Lists Fail Patients

    Why harm comes from treating a changing regimen like a static list, not from missing paperwork alone.

  2. 7:00

    Highest-Risk Transition Points

    Compare admission, internal transfer, discharge, and post-acute handoff. Each creates its own error pattern.

  3. 17:00

    Where Histories Go Wrong

    See how recall limits, fill history, and false certainty distort the best possible medication history.

  4. 26:00

    Ordering And List Drift

    How shaky lists become active treatment errors through substitutions, copy-forward, duplicates, and defaults.

  5. 36:00

    Discharge Creates New Errors

    Why discharge often adds discrepancies when inpatient decisions and outpatient reality meet a printer.

  6. 48:00

    High-Risk Patients And Drugs

    Focus on polypharmacy, fragmented care, and medication classes where reconciliation failures cause more harm.

  7. 55:00

    Measures, Recap, And Q&A

    What to measure, what completion rates miss, and how to choose one narrow fix for your setting.

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