Medication Reconciliation Playbook

Make every transition safer by creating and sustaining accurate medication lists at admission, transfer, and discharge.

Why this matters

Medication errors at transitions are a common source of harm—missing medicines, unintended duplications, incorrect doses, and poor communication between teams can lead to adverse drug events, delays, and readmissions. This playbook gives practical, adaptable tools teams can use today to reduce those risks and improve continuity of care.

What you'll understand and be able to do

After using this playbook you and your team will be able to:

• Describe a standardized medication reconciliation workflow for admission, internal transfer, and discharge;
• Assign and document clear roles and handoffs between nurses, pharmacists, physicians, and care coordinators;
• Use checklists, an SOP, and an admission‑to‑discharge form to collect accurate home and inpatient medication information;
• Run audits using the included audit checklist to measure completeness and identify improvement opportunities;
• Adapt templates to local formularies, EHR workflows, staffing models, and regulatory requirements.

Who benefits

This resource is most useful for interprofessional teams responsible for transitions of care: hospital units, emergency departments, discharge planners, pharmacists, primary care practices, skilled nursing facilities, home health agencies, ambulatory surgery centers, and behavioral health services. Quality and safety leaders, clinical educators, and frontline clinicians will find practical steps to reduce medication‑related risk today.

Practical examples

- A hospital med‑surgery unit uses the admission checklist and single‑source medication form to reconcile home meds at intake and again at discharge, then runs the audit checklist monthly to track missed doses and documentation gaps.

- A skilled nursing facility adapts the SOP and transfer checklist to align with its eMAR and incoming transfer paperwork, reducing duplicate anticoagulant orders after hospital handoffs.

- A home health team pairs the admission‑to‑discharge form with a pharmacist phone follow‑up for high‑risk patients to catch discrepancies after discharge from the hospital.

How to use the playbook — practical next steps

Start small and iterate: map your current handoffs, choose one transition (admission or discharge) to standardize first, assign accountable roles, pilot the checklist on a single unit or clinic, and use the audit template to collect baseline data. Adapt language and fields to match your formulary and EHR, train staff with short huddles, and repeat audits to show improvement.