How Care Transitions Complicate Medication Management — and How to Fix Them

“What’s this drug, Dad?” I held up a colorful capsule from his pill box as we were packing for a family vacation. “I have no idea,” he shrugged. I urged him to clarify the mystery medication with his primary care physician. It was an antiarrhythmic drug that his cardiovascular surgeon had prescribed after coronary artery bypass surgery over two years prior. It was only intended to be used for a few weeks post-op. No one was monitoring for side effects, checking medication blood levels — or, more importantly, questioning why he was still taking the drug. 

My dad’s experience isn’t uncommon. As healthcare becomes increasingly fragmented, medication management during care transitions has become a key patient safety challenge. Up to 80 percent of patients discharged from hospitals experience at least one medication discrepancy or communication failure about in-hospital medication changes. Every transition point — in my dad’s case, pre-op to post-op, inpatient to outpatient, and specialist consultant care to primary care — creates opportunities for inadvertent medication mismanagement that can profoundly impact patient outcomes. 

Clinicians must conduct regular medication reconciliation to know everything their patients are taking — and why — but it may seem difficult to fully capture in a short visit. By combining low-tech strategies with software that identifies opportunities to reduce the threat of drug interactions or complications, comprehensive and routine medication reconciliation becomes doable. 

The complexity and complications of modern care transitions 

Care transitions result in several medication management issues repeatedly seen in clinical practice. A primary complication affecting one in five older Americans is polypharmacy, defined as taking five or more prescription drugs simultaneously. 

As care becomes increasingly specialized and patients see multiple doctors to manage their health, their pill boxes may fill up with medications from disconnected prescribing clinicians. That can be dangerous. Taking many medications increases the likelihood and unpredictability of drug interactions. If, for example, an emergency physician adds tramadol for acute pain, unaware of the patient’s SSRI prescription, they risk serotonin syndrome. Patients prescribed short courses of steroids or antibiotics during an inpatient stay may remain on them indefinitely without clear end dates entered in the EHR. Add to that the over-the-counter medications, herbs, and supplements that 75 percent of patients take. These are often a blind spot for clinicians that can affect safety profiles and interact with prescription drugs. St. John’s Wort, for instance, can render transplant medications ineffective, and seemingly benign NSAIDs can precipitate renal failure in susceptible patients. 

Polypharmacy puts older patients at particular risk. The physiological changes of aging can make previously safe medications hazardous. For example, benzodiazepines may increase falls, and anticholinergics may worsen cognition. About one in three older adults are prescribed these potentially inappropriate medications. 

Without a clear view of each medication, supplement, herb, and over-the-counter medication their patients take, clinicians lack insight into whether continuing on their current regimen or deprescribing could improve their outcomes. Solving these and other medication management problems will require clinicians to take ownership of their patients’ full medication lists—but they need the right tools and strategies to do so. 

Balancing low- and high-tech approaches to medication management

Data and technology increasingly support medication management. Clinicians can use prescription and EHR data to reconcile active medication lists against filled prescriptions, flag drug interactions, or list what a medication is for (for example, “for blood pressure”) to improve patient understanding. Patient portals empower patients to share which medications they’re taking, and drug information references can help identify mystery pills or offer in-depth prescribing information. 

But the accuracy of these technologies relies entirely on the quality of their data. When active medication lists aren’t updated after specialist visits, EHRs aren’t interoperable, or patients don’t report over-the-counter drugs, even the most sophisticated clinical decision support systems will fail. 

One way to overcome technological data limitations is to go old-school, with an annual “brown bag” medication review. Ask patients to bag up all their prescriptions, over-the-counter medications, herbs, and supplements — in their original containers — and bring them to their primary care office for documentation. Logging each item is time consuming, but this low-tech approach makes visible what technology misses. The insulin doses patients are skipping or splitting due to high cost, herbal supplements that were never disclosed, and, in my dad’s case, short-term medications still in the pill box come to light, offering a tangible opportunity to check for interactions and identify inappropriate medications.

Moving forward

Optimal medication management during care transitions requires hybrid approaches. Technology must continue advancing toward interoperability, but we cannot wait for perfect systems. Every clinical encounter must be viewed as a medication reconciliation opportunity. Primary care clinicians should routinely ask about all medications and supplements, and encourage patients to “brown bag it” once a year. 

As the coordinator-in-chief, primary care practices own the entire medication list — regardless of who prescribed which drug. We must recognize medication safety as a communication and coordination challenge requiring systematic attention to the predictable risks of an increasingly fragmented healthcare system.

Photo: bong hyunjung, Getty Images

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