Why coordinated medication management matters across healthcare settings
Patients receiving multiple medications may face an increased risk of medication discrepancies, drug interactions, adverse drug events and challenges with treatment adherence. These risks can become more significant when patients move between healthcare settings, such as from hospital to home, between hospital departments or from specialist care to primary care.
Safe transitions of care require accurate medication information, clear communication between healthcare professionals and active involvement of patients and caregivers. A structured approach can help ensure that medication changes are appropriate, documented and understood.
Understanding polypharmacy and its associated risks
Polypharmacy generally refers to the use of multiple medications by one individual. Although taking several medicines may be clinically appropriate for patients with multiple chronic conditions, it can increase treatment complexity and the potential for medication-related problems.
Common challenges include drug–drug interactions, duplicate therapies, inappropriate doses, adverse effects and difficulties following complex medication schedules. Older adults and people with multiple chronic conditions may be particularly vulnerable because of changes in kidney or liver function, frailty and increased sensitivity to certain medicines.
Importantly, the number of medicines alone does not determine whether treatment is appropriate. The focus should be on whether each medicine has a valid indication, provides meaningful benefit and remains safe for the individual patient.
Why are transitions of care particularly vulnerable?
During transitions, medication information may be incomplete, outdated or inconsistent across medical records. Patients may also receive prescriptions from multiple clinicians, making it difficult to maintain an accurate and consolidated medication list.
Common transition-related problems include:
Unintentional medication omissions: Regular medicines are accidentally excluded from admission or discharge orders.
Unintended duplication: Medicines with similar ingredients or therapeutic effects are prescribed without a clear rationale.
Incorrect doses or schedules: Changes made during hospitalisation are not accurately communicated to the next care provider.
Inappropriate continuation: A medicine intended for short-term use is continued beyond the planned duration.
Unclear medication changes: Patients are not informed about which medicines have been started, stopped or modified.
These gaps can contribute to preventable medication-related harm, treatment interruptions and avoidable healthcare utilisation.
Medication reconciliation: A critical safety measure
Medication reconciliation is a structured process that involves obtaining an accurate medication history, comparing it with current prescriptions, identifying discrepancies and resolving unintended differences.
For patients with polypharmacy, the process should include prescription medicines, over-the-counter products, vitamins, herbal preparations and other relevant supplements.
A practical approach includes five steps:
1. Obtain the best possible medication history
Collect information from the patient or caregiver and verify it using available sources, such as prescription records, pharmacy information and previous medical records. Document the medicine name, dose, route, frequency and how the patient actually takes it.
2. Compare medication lists
Review the existing regimen against admission, transfer or discharge orders. Identify missing medicines, duplicate therapies, dose discrepancies and medicines that may no longer be necessary.
3. Conduct a clinical medication review
Assess the indication, effectiveness, safety and suitability of each medicine in the context of the patient's current clinical condition, treatment goals, comorbidities and relevant laboratory findings.
4. Resolve and document discrepancies
Clarify unexplained differences with the responsible prescriber or pharmacist. Record the decisions made, including medicines started, stopped or adjusted, and the rationale where appropriate.
5. Communicate the final medication plan
Ensure that the reconciled list is shared with the receiving healthcare team and explained to the patient or caregiver. Provide clear instructions about medication changes and any required monitoring or follow-up.
Deprescribing and appropriate medication review
Transitions of care also provide an opportunity to assess whether the existing treatment regimen remains appropriate. Deprescribing involves the supervised reduction or discontinuation of medicines when their potential harms outweigh their expected benefits or when they are no longer indicated.
However, medicines should not be stopped solely because a patient takes many medications. Decisions should consider the original indication, current clinical status, expected benefits, potential withdrawal effects and patient preferences.
A structured, person-centred review can help clinicians identify unnecessary treatment while preserving essential therapies. Where medicines require tapering or close monitoring, an appropriate plan should be documented and communicated.
The role of multidisciplinary collaboration
Safe medication management is a shared responsibility across the healthcare team.
Physicians and prescribers assess the clinical appropriateness of treatment and make decisions about starting, adjusting or discontinuing medicines.
Pharmacists support medication-history verification, identify potential interactions and discrepancies, and provide counselling on safe medicine use.
Nurses help verify medication information, reinforce discharge instructions and identify concerns during care transitions.
Patients and caregivers provide information about actual medicine use, communicate concerns and participate in shared decisions.
Clear allocation of responsibilities and timely information exchange are essential, particularly when patients receive care from multiple providers.
Empowering patients and caregivers
Patients with complex medication regimens may find it difficult to remember medicine names, doses and schedules, especially after hospitalisation.
Healthcare professionals can support safer transitions by providing an updated medication list in an understandable format, explaining the purpose of each medicine and highlighting important changes. Teach-back—asking patients to explain the instructions in their own words—can help identify misunderstandings before discharge.
Patients should also know whom to contact if they experience side effects, have difficulty obtaining medicines or are uncertain about their regimen.
Strengthening systems for safer transitions
Healthcare organisations can improve medication safety by incorporating reconciliation into admission, transfer and discharge workflows; maintaining accessible medication records; standardising handover documentation; and providing staff training.
Electronic health records and medication-management tools may support information sharing, but they do not replace clinical verification or direct communication. Organisations should also monitor process indicators, such as the completion of medication reconciliation, unresolved discrepancies and timely communication with receiving providers.
Every transition is an opportunity to verify, review and optimise medication use.
This article is intended for healthcare professional education. Clinical decisions should be individualised and aligned with local guidelines and institutional protocols.