PICOT Clinical Question
Medication safety during the transition from hospital to home is a persistent clinical problem because patients often leave acute care with medication regimens that differ substantially from those they used before admission. Drugs may have been started, stopped, substituted, temporarily withheld, or dose-adjusted during hospitalization, and these changes can become confusing when the patient receives multiple lists or incomplete explanations. The risk is especially high for older adults, people with several chronic conditions, patients taking many medicines, those using high-risk drugs, and individuals with limited health literacy or fragmented follow-up. The clinical question guiding this evidence-based proposal is: In adult acute-care patients (P), does implementation of a standardized nurse-led medication-reconciliation and transition-of-care bundle (I), compared with usual discharge practice (C), reduce medication discrepancies and preventable medication-related harm (O) within 30 days after discharge (T)? This question identifies a defined patient population, a practical intervention, a comparison condition, measurable outcomes, and a realistic follow-up period. The proposed intervention is not medication reconciliation as a single checklist. It is a structured transition process that combines reconciliation, discrepancy resolution, patient education, an understandable final medication list, and early post-discharge follow-up.
Medication-Related Harm
Hospital discharge is a vulnerable point because responsibility for medication management shifts rapidly from an inpatient team to the patient, family, primary-care clinician, community pharmacist, and other outpatient professionals. Information may be incomplete or inconsistent across electronic records, referral documents, pharmacy systems, and the patient’s own recollection. A medication discrepancy can involve an omitted medicine, an unnecessary duplicate, the wrong dose or frequency, continuation of a drug that should have been stopped, or failure to restart an appropriate chronic treatment. Even when the discharge list is technically correct, harm can occur if the patient does not understand why a change was made or which medicine should replace an older prescription. The World Health Organization identifies transitions of care as a major medication-safety priority because preventable harm often arises when accurate information is not transferred effectively between settings (WHO, 2024). The Agency for Healthcare Research and Quality similarly emphasizes that medication reconciliation requires obtaining the most accurate medication history possible, comparing that history with current orders, resolving unintended discrepancies, and clearly communicating the final regimen rather than simply copying a medication list from the chart (AHRQ, 2023).
The consequences extend beyond clerical errors. Medication problems after discharge can contribute to adverse drug events, treatment failure, emergency visits, readmissions, and loss of confidence in the healthcare system. High-risk medications such as anticoagulants, insulin, opioids, and medicines with narrow therapeutic ranges require particularly careful communication because small misunderstandings can lead to serious harm. Patients may also face practical barriers, including inability to afford a newly prescribed medicine, difficulty obtaining a prescription quickly, language differences, cognitive impairment, or conflicting instructions from multiple clinicians. These factors show why a single intervention is unlikely to solve the problem. A printed medication list cannot correct an inaccurate history; reconciliation without patient education may leave the regimen misunderstood; and education without follow-up may fail when a patient discovers a problem after returning home. The clinical problem therefore calls for a bundled approach that addresses accuracy, communication, understanding, and continuity as connected parts of the same transition.
Nurse-Led Care Bundle
The proposed intervention begins with a best possible medication history obtained or verified by the nurse using more than one source when necessary. The patient or caregiver should be asked what is actually being taken at home, including prescription medicines, over-the-counter products, supplements, and medicines taken only when needed. The list should then be compared with available pharmacy information, prior records, or other reliable sources when discrepancies remain. Before discharge, preadmission medicines, inpatient orders, and the proposed discharge regimen should be reviewed together so that unexplained differences can be escalated to the prescriber or pharmacist. The purpose is not to make the nurse solely responsible for prescribing decisions. Instead, the nurse acts as a consistent coordinator who identifies potential discrepancies, ensures that unresolved questions reach the appropriate clinician, and verifies that the final instructions match the agreed medication plan. This approach fits nursing practice because nurses already administer medications, observe patient responses, assess understanding, coordinate discharge preparation, and communicate across professional boundaries.
The second part of the bundle focuses on communication with the patient. Each patient should receive one final, patient-friendly medication list that clearly states what to continue, what to stop, what has changed, and what has been newly prescribed. The list should avoid unnecessary technical language and should be available in the patient’s preferred language when feasible. Rather than asking whether the instructions are understood, the nurse should use teach-back by asking the patient or caregiver to explain the regimen in their own words. Misunderstandings can then be corrected before discharge. High-risk medicines deserve extra attention to dose, timing, monitoring, warning signs, and what to do if a dose is missed. The bundle should also include confirmation that prescriptions can actually be obtained and that follow-up is arranged when needed. A brief telephone or electronic contact within several days of discharge can identify problems that appear only after the patient attempts to follow the new regimen at home. If the patient reports confusion, side effects, inability to obtain a drug, or conflicting advice, the concern should be routed promptly to the appropriate clinician.
Supporting Evidence
Recent evidence supports combining medication reconciliation with broader transition-of-care activities rather than relying on reconciliation alone. Harris et al. (2022) reviewed pharmacy-led transitions-of-care interventions and found that medication reconciliation was among the most common components, while many studies reported reductions in hospital readmission or improvements in other medication-related outcomes. The findings also showed substantial variation among interventions, which is important because “medication reconciliation” can describe very different levels of intensity. Some programs simply compare lists, whereas others add counseling, communication with outpatient clinicians, follow-up, or pharmacist review. Foot et al. (2022), in a systematic review and meta-analysis of pharmacist-physician collaboration, also found that collaborative medication-management approaches can improve outcomes when professional roles are coordinated. These findings support an interdisciplinary model in which nurses lead the transition workflow but have clear access to pharmacists and prescribers for clinical review and discrepancy resolution.
Evidence-based practice also depends on the competence and readiness of the staff implementing the change. Crawford et al. (2023) found that nurses’ engagement with evidence-based practice is influenced by organizational support, knowledge, confidence, time, and access to resources. A new reconciliation process should therefore not be introduced as an additional form without training and workflow support. Nurses need clear definitions of what counts as a discrepancy, guidance for obtaining a medication history, escalation pathways, teach-back training, and documentation standards. Advanced-practice nursing evidence likewise emphasizes the importance of competence in locating, evaluating, and applying evidence in clinical care (Ylimäki et al., 2024). The WHO’s medication-safety work and the AHRQ MATCH toolkit reinforce the same principle from a systems perspective: medication safety improves when organizations standardize responsibility and communication at transitions rather than expecting individual clinicians to compensate for inconsistent processes (WHO, 2024; AHRQ, 2023). The proposed bundle therefore uses evidence not only to select clinical activities but also to design a reliable implementation process.
Implementation and Evaluation
A practical implementation could begin on one adult medical or surgical unit rather than across the entire hospital. An initial pilot population might include patients taking five or more chronic medications, those prescribed high-risk medicines, patients with major medication changes during hospitalization, or individuals with a recent readmission. Starting with a defined group makes training and data collection manageable while targeting patients most likely to benefit. Before implementation, the team should measure the current frequency of medication discrepancies and 30-day medication-related utilization so that post-intervention outcomes can be compared with a baseline. Nurses, pharmacists, physicians, case managers, information-technology staff, and quality personnel should agree on the workflow and determine where responsibilities begin and end. Electronic documentation should support the process rather than create duplicate work. Ideally, the final reconciled medication list should become the single source used for patient instructions and downstream communication.
The primary outcome should be the number or proportion of patients with clinically significant unintended medication discrepancies after discharge. A structured review can classify discrepancies by type and potential severity. A second major outcome should be preventable medication-related harm within 30 days, which may include adverse drug events, emergency visits, or readmissions judged to be medication related. Process measures are also necessary because an intervention cannot be evaluated fairly if it is not consistently delivered. Useful process measures include the percentage of eligible patients receiving a verified medication history, completion of reconciliation before discharge, documented teach-back, delivery of the final medication list, and successful follow-up contact. Balancing measures should assess whether the bundle creates excessive discharge delays or unrealistic nursing workload. Patient-reported understanding of the medication plan can provide an additional measure of quality. Improvement should be reviewed over several cycles so that the team can identify where the workflow fails and modify it without weakening the essential components.
Clinical Sustainability
The value of this PICOT intervention lies in treating medication safety as a transition problem rather than an isolated documentation task. A medication list can be accurate in the hospital and still fail if the patient does not understand it, if the community clinician receives different information, or if a new prescription cannot be obtained. A nurse-led bundle addresses these points because nurses are positioned at the intersection of medication administration, patient education, discharge planning, and interdisciplinary communication. Leadership is important, however, because adding responsibility without adequate staffing or escalation support can make the process unsustainable. The organization should identify which patients require the full bundle, integrate prompts into existing documentation, use pharmacist expertise for complex cases, and audit a small set of meaningful measures rather than create excessive data collection. If the pilot demonstrates fewer discrepancies without unacceptable delays, the process can be expanded gradually to additional units and adjusted for populations such as older adults, patients with language needs, or those discharged to other care facilities.
Sustainability also requires attention to variation in real-world care. Not every discrepancy is clinically important, and not every readmission is preventable. Teams should review adverse events and near misses to determine whether the workflow could have prevented them. Feedback should then be returned to frontline staff so that the project remains a learning system rather than a compliance exercise. The 30-day time frame in the PICOT question is useful because it captures an important period after discharge while remaining feasible for quality measurement. Over time, the organization could also examine patient experience, medication adherence, cost, and equity. If certain groups continue to experience more discrepancies, the intervention may need stronger language services, caregiver involvement, pharmacy coordination, or access support. In this way, the PICOT framework provides a starting structure for a clinically meaningful change rather than an endpoint.
Conclusion
Medication discrepancies during the transition from acute care to home are preventable sources of patient harm that require more than a final check of the electronic medication list. The proposed PICOT intervention uses a standardized nurse-led bundle that combines an accurate medication history, comparison and resolution of discrepancies, a clear final medication plan, teach-back, attention to high-risk medicines, and early follow-up after discharge. Recent evidence supports coordinated transitions-of-care interventions and interdisciplinary medication management, while current WHO and AHRQ guidance emphasizes structured reconciliation and communication across transitions. The intervention should be evaluated through both clinical outcomes and process measures, including unintended discrepancies, medication-related harm within 30 days, completion of bundle components, patient understanding, and the effect on workflow. Nurses are well positioned to coordinate the process, but successful implementation depends on clear collaboration with pharmacists and prescribers, appropriate training, and organizational support. If implemented reliably, the bundle offers a practical evidence-based strategy for making discharge medication plans more accurate, understandable, and safer for adult acute-care patients.
References
Agency for Healthcare Research and Quality. (2023). Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. U.S. Department of Health and Human Services.
Crawford, C. L., Rondinelli, J., Zuniga, S., Valdez, R. M., Tze-Polo, L., & Titler, M. G. (2023). Testing of the Nursing Evidence-Based Practice Survey. Worldviews on Evidence-Based Nursing, 20(1), 27–36. https://doi.org/10.1111/wvn.12618
Foot, H., Scott, I., Sturman, N., Whitty, J. A., Rixon, K., Connelly, L., & Denaro, C. (2022). Impact of pharmacist and physician collaborations in primary care on reducing readmission and adverse events: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 18(6), 2922–2943. https://doi.org/10.1016/j.sapharm.2021.07.015
Harris, M., Joseph, J., & Hovey, S. (2022). Pharmacy-led transitions of care interventions: A systematic review. Journal of the American Pharmacists Association, 62(5), 1477–1498.e8. https://doi.org/10.1016/j.japh.2022.05.017
World Health Organization. (2024). Medication without harm: Policy brief. World Health Organization.
Ylimäki, S., Kanste, O., Heikkinen, K., Bloigu, R., & Kyngäs, H. (2024). Advanced practice nurses’ evidence-based healthcare competence and associated factors: A systematic review. Journal of Clinical Nursing, 33(6), 2069–2083. https://doi.org/10.1111/jocn.17075
Academic Master Education Team is a group of academic editors and subject specialists responsible for producing structured, research-backed essays across multiple disciplines. Each article is developed following Academic Master’s Editorial Policy and supported by credible academic references. The team ensures clarity, citation accuracy, and adherence to ethical academic writing standards
Content reviewed under Academic Master Editorial Policy.
