Coming Home From the Hospital: A Medication Guide for Families

The First Week Home Is the Riskiest Medication Week of Your Parent’s Year

Start with the numbers, because they are bleak enough to warrant taking this seriously.

A landmark prospective study by Forster and colleagues found that nearly 20% of patients experience at least one adverse event within three weeks of hospital discharge, and adverse drug events (ADEs) are the single most common category of post-discharge complication. Of those events, roughly three-quarters were judged preventable or ameliorable. The HHS National Action Plan for Adverse Drug Event Prevention cites the same body of evidence, noting that ADEs accounted for two-thirds of all post-discharge complications in at least one tertiary-care dataset.

Among adults aged 65 and older, a 2021 analysis concluded that 40% of 30-day readmissions were possibly medication-related. A 2025 PLOS ONE study of 4,012 elderly patients found that those discharged on even one potentially inappropriate medication had a 7.96% rate of unplanned readmission or ED visit within 90 days, compared with 5.20% for those without.

The specific window matters. Among older adults who had cardiometabolic medication changes at discharge, 39% had already made at least one medication error within 7 days, rising to 50% by 90 days. That was true even though nearly all of them told the research team they understood the purpose of their medications. Understanding was not enough.

For high-risk drug classes, the numbers are worse. Elderly patients started on opioids for a medical hospitalization had a 7.0% rate of a potential opioid-related ADE within 30 days, concentrated in the first week. For anticoagulated patients, the hemorrhage and thromboembolism rates per 100 person-years are at their absolute peak during the first 30 days after discharge, falling substantially over the following eleven months.

A 2019 systematic review in Prescriber named the 7-day post-discharge window as the highest-risk period for adverse drug reactions in older adults, full stop.

This is not because hospitals are careless. It is because the moment a patient crosses the front door going out, the system of professionals who were reviewing every dose against every lab value every day simply stops. And the system at home is not built to catch what the system inside the hospital was catching.

Why Discharge Goes Wrong (even when everyone is trying)

Everybody you meet during a discharge is trying. The nurse handing you the paperwork is trying. The hospitalist signing orders is trying. The pharmacist, if you get one, is trying. The structural problem is that their work is being stitched together under time pressure, and the seams are where families get hurt.

”Medically stable” is not “safe at home”

U.S. hospitals can legally discharge a patient the moment they are judged “medically stable,” which is not the same thing as being safe to manage medications alone at home. One r/eldercare user put this bluntly after an unsafe discharge of a grandmother with dementia: “Hospitals are permitted to release patients once they are deemed ‘medically stable,’ rather than when they are considered ‘safe at home.’” The hospital’s decision point is physiology. Safety at home is a very different question, and it is the one you are being handed.

The discharge pharmacist gap

There is supposed to be a pharmacist reviewing the final discharge medication list. In theory, that person confirms what is new, what is changed, what is stopped, what needs a planned end date, and what cannot be taken with what.

In a 2022 multi-hospital study, 74.9% of older patients had a pharmacist interview during hospitalization, but only 47.8% reported any conversation with a healthcare professional about their medication changes. Even more telling, 41% of patients who received admission medication reconciliation did not receive discharge medication reconciliation, mostly because the pharmacist was not notified the patient was leaving or ran out of time.

Put plainly: the person most qualified to catch the mistake in the discharge list often isn’t told the patient is going home.

When pharmacists are integrated into discharge, the effect is large. A pilot at BayCare Health System reduced 30-day readmissions from 15.9% to 9.0% by adding pharmacist-led discharge reconciliation and 72-hour follow-up. Structured pharmacist-led transitions-of-care services cost roughly $101 per hospitalization according to a 2023 Nuckols analysis. The evidence is not the problem. Adoption is.

The paperwork problem

The discharge summary, the document that tells your parent’s primary care doctor what happened in the hospital, is supposed to arrive at the PCP’s office before the follow-up visit. In practice, systematic reviews have found that discharge summaries often arrive late or never. Even when they arrive, the patient-facing version is frequently written above the recommended reading level. A trauma discharge summary study found the documents averaged a 10th-grade reading level when the AMA, HHS, and NIH all recommend a 6th-grade level. Only 24% of patients in that study had the literacy to fully understand their discharge documentation. Two-thirds of Americans over 60 already have inadequate or marginal health literacy, and hospitals compound that by writing above their audience.

The handoff problem

The final structural issue is the one caregivers feel most viscerally. Your parent’s medications are not in one place. They are spread across a hospital record, one or two community pharmacies, maybe a mail-order plan, plus any GoodRx cash fills, plus samples, plus OTC supplements. One caregiver in r/CaregiverSupport put the reality out loud: “The discharge process is almost always chaotic. Medication reconciliation can be error-prone, such as prescribing a new statin while still keeping the old one. If a patient doesn’t consistently visit the same pharmacist or the pharmacist isn’t attentive, these mistakes can slip through.”

I see that pattern constantly. The home regimen and the discharge regimen collide, nobody is looking at both lists at once, and duplicates or omissions slip through.

The Five Medications Most Likely to Go Wrong After Discharge

Across federal datasets and published studies, five drug classes account for a disproportionate share of post-discharge harm in older adults. I’ve written separately about the Beers Criteria and which drugs I actually worry about, but the discharge picture is its own specific problem, because it is about what the hospital added, changed, or didn’t stop.

1. Anticoagulants (warfarin, apixaban, rivaroxaban)

Blood thinners are the drug class most likely to send an older adult back through the ED in the first month after discharge. A Hawkins study (CMAJ Open, 2021) found that switching anticoagulant class in the hospital doubles the risk of a subsequent adverse drug event. That matters because hospitals often switch a patient’s home warfarin to a DOAC during an admission (or vice versa), and the dose, timing, and interaction profile change with it.

Anticoagulants are also the class most vulnerable to drug-drug collisions. Trimethoprim-sulfamethoxazole (Bactrim) added to warfarin within 14 days carries a 2 to 3.84-fold higher risk of GI-bleeding hospitalization. I have seen that exact setup on a discharge list more than once: a short antibiotic course prescribed on the way out the door, a home warfarin that nobody thought to flag, and a family that ends up back in the ED eight days later.

Red flags to watch in the first 7 days: unusual bruising, blood in urine or stool, black stool, bleeding from the gums that does not stop, a sudden severe headache, prolonged bleeding from a minor cut.

2. Insulin and oral antihyperglycemics

New insulin started in the hospital is one of the most quietly dangerous discharge decisions, because the dose that was right when the patient was sick, underfed, and being watched every four hours is almost never the right dose at home.

The Lipscombe study (J Gen Intern Med, 2019) found that new in-hospital insulin initiation was associated with a 1.59-fold higher risk of 30-day mortality compared with patients on stable oral agents. Hypoglycemia itself independently doubles 30-day mortality (OR 2.02). On the other end, 13.4% of patients discharged after a heart attack had their diabetes medication discontinued on the way out, which is independently associated with a 29% higher one-year mortality.

Translation: both continuing a too-high dose and stopping a drug that should have continued can hurt your parent. This is one of the categories where a pharmacist review of the discharge list matters most.

Red flags: sweating, shakiness, a fast or pounding heartbeat, sudden confusion, weakness, nausea. Check blood sugar immediately. Low blood sugar in an older adult can look like a stroke.

3. Opioids

If your parent was sent home with a new opioid prescription, the risk window is short and steep. A cohort of elderly opioid recipients had 1.7 times higher 30-day mortality and 1.2 times higher odds of any adverse effect than a matched group on NSAIDs. The number-needed-to-harm for any ADE was 26, which is a small number in clinical research.

Opioids in older adults cause falls, fractures, delirium, slowed gut motility leading to impaction, and respiratory depression. A benzodiazepine added to an opioid, which happens more often than it should, multiplies the respiratory depression risk.

Red flags: excessive sedation (hard to wake, sleeping through meals), respiratory rate below 12 breaths per minute, no bowel movement for 3 or more days, confusion that is new since discharge, slurred speech, falls.

4. Antipsychotics started in the hospital

This is the one I worry about the most, because it almost never gets discussed at discharge.

Delirium is common in hospitalized older adults (20 to 30%), and antipsychotics like quetiapine, olanzapine, or haloperidol are frequently started to manage agitation. Across a 22-hospital system, 4% of non-psychiatric inpatients who received a newly initiated antipsychotic were discharged on one. In the ICU, 23% of atypical antipsychotic starts continue after discharge. Very few of those patients have a psychiatric indication for chronic use.

A 2025 JAMA Psychiatry cohort study by Gerlach and colleagues looked at two nationwide U.S. cohorts and found that discontinuing antipsychotics after discharge was associated with lower rehospitalization and lower all-cause mortality than continuing them, across age, sex, and dementia status. The 2023 American Geriatrics Society Beers Criteria give a strong recommendation to avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options have failed, and to attempt periodic deprescribing.

If your parent was started on quetiapine, risperidone, olanzapine, or haloperidol during their hospital stay, the question to ask the discharging team is: “Is this meant to continue, and if so, when are we planning to stop it?” There should be a specific answer. “Just keep taking it” is not one.

Red flags: muscle stiffness, unusual involuntary movements, tremor, fever with rigidity (which can signal neuroleptic malignant syndrome), a shuffling gait that wasn’t there before, falls.

5. PPIs, sleep aids, and muscle relaxants

I call these the silent-migration drugs. Nothing dramatic happens in the first week. They just quietly become part of the chronic regimen and stay for years.

Proton pump inhibitors (PPIs) are often started in the ICU for stress-ulcer prophylaxis. In one large analysis of ICU admissions, about 60% of new PPI starts lacked a long-term indication but were continued at discharge. About 1 in 6 ICU PPI starts are inappropriately continued. Long-term unnecessary PPI use has been associated with a 27% increased risk of pneumonia compared with patients who stopped at discharge.

Benzodiazepines and Z-drugs started for inpatient insomnia or anxiety: about 15% of older adults are still taking benzodiazepines two months after hospitalization. These agents drive falls, fractures, cognitive impairment, and delirium in older adults, and the STOPP criteria explicitly recommend against use beyond 4 weeks.

Muscle relaxants (cyclobenzaprine, methocarbamol, carisoprodol) sit on both the NCQA high-risk medication list and the AGS Beers Criteria for older adults. They tend to get started for inpatient musculoskeletal pain and then never stopped.

None of these drugs are wrong in every context. The problem is that a patient who went into the hospital on ten medications and comes home on fourteen has usually picked up at least one of these, and no one has written a stop date.

Your 72-Hour Checklist

This is the save-to-your-phone section. Each item has a short “why this matters” tag attached because the reason behind the action is what makes you do it when you’re exhausted.

Hour 0 — Before you leave the hospital

1. Get a printed, reconciled discharge medication list in plain language. Every drug, the dose, the frequency, the reason it’s on the list, and whether it is new, changed, or unchanged from before the hospital stay. Why this matters: Less than half of discharge prescriptions include documentation of the changes made during the admission.

2. Confirm every medication can actually be obtained before you leave the building. Ask the discharge nurse or case manager whether there are any prior authorizations, formulary substitutions, or supply issues on any drug on the list. For anticoagulants, insulin, and antihypertensives, even a one-day gap is dangerous. Why this matters: Access problems are a leading cause of preventable early readmissions. The AHRQ RED Toolkit specifically lists “identify the correct medicines and a plan for the patient to obtain them” as a core discharge action.

3. Ask for (and actually get) a conversation with a pharmacist. Say it plainly: “Before we leave, I want a pharmacist to go through this list with us.” If the answer is “that’s not available today,” ask the charge nurse to page one. Why this matters: 41% of patients who get admission medication reconciliation do not get discharge medication reconciliation, almost always because the pharmacist was not notified.

First 24 hours at home

4. Put the old pill bottles next to the new list. Classify every item as: same, changed dose, new, or removed. Use a pen and mark each bottle. Why this matters: The most common type of discharge prescription error is omission. In one critical-care cohort, 96% of discharge discrepancies in older adults were omissions.

5. Report anything in the “removed” pile to the prescriber the same day. Ask specifically: was this an intentional stop or an accidental omission? Write down the answer. Why this matters: Omission of a chronic medication (blood thinner, antidepressant, Parkinson’s medication, thyroid replacement) can cause harm faster than any new drug will.

6. For every new drug started in the hospital, ask for a planned stop date. Especially antipsychotics, benzodiazepines, Z-drugs, PPIs, and muscle relaxants. If the answer is vague, write down the drug name and the word “indefinite?” on the list so it comes up at the follow-up visit. Why this matters: 23% of ICU antipsychotic starts, roughly 15% of hospital benzodiazepine starts, and about 1 in 6 ICU PPI starts continue indefinitely without an ongoing indication.

48 hours

7. Schedule the 5-to-7-day follow-up appointment if the hospital didn’t. Call the primary care office as soon as they open the morning after discharge. Say your parent was discharged and needs to be seen within the week. Why this matters: A 599-hospital survey found that arranging the follow-up appointment before discharge is one of only three hospital strategies independently associated with lower 30-day readmission rates.

8. Open every bottle, read every label out loud, set up the pill organizer together. Don’t hand a list to your parent and assume they’ll get it. Do it with them, the way a nurse would do teach-back. Why this matters: In a cohort of older adults with cardiometabolic medication changes, 39% had made at least one error within 7 days even though nearly all reported understanding their regimen. Understanding at the bedside does not translate to correct behavior under stress at home.

72 hours

9. Call the community pharmacist for a comprehensive medication review. Go to the pharmacy where your parent fills most of their prescriptions, bring the discharge list, and ask for a pharmacist-led review. Medicare Part D plans include Medication Therapy Management (MTM) at no additional cost for many beneficiaries. Why this matters: Pharmacist involvement reduces medication errors by 32% in patients with low health literacy, and two-thirds of Americans over 60 fall into that category.

10. Walk through the red-flag symptoms for each drug class with your parent and any other caregivers in the home. Take five minutes per class. Write the red flags on a card on the refrigerator. Why this matters: The Coleman CTI, one of the most-studied transition-of-care interventions, built its effect partly on teaching patients and families to recognize class-specific warning signs before they become emergencies.

Three Questions to Ask at Discharge (and What Good Answers Sound Like)

Ask these of whoever is signing the discharge paperwork — hospitalist, resident, discharge nurse, pharmacist. If you can get them in writing, even better.

Question 1: What changed from my parent’s home medication list, and why? Good answer: Specific. “We added apixaban because of the new atrial fibrillation. We stopped lisinopril because the potassium got too high. We switched metoprolol tartrate to metoprolol succinate so it can be once a day.” Bad answer: “Everything is on the list.” That tells you the person saying it has not looked.

Question 2: Which of these medications has a planned stop date, and which are indefinite? Good answer: Specific. “The antibiotic ends on the 27th. The antipsychotic is for the delirium from this admission; we’re planning to taper it off at the 2-week follow-up. The blood thinner is indefinite. The PPI was for stress ulcer prophylaxis in the ICU; I’m going to write an order to stop it today.” Bad answer: “Just keep taking all of them.”

Question 3: Who do I call if something seems wrong in the first 72 hours? Good answer: A direct phone number for the discharge pharmacy or the attending’s office, an after-hours number, plus a clearly stated 911 threshold for bleeding, chest pain, or sudden confusion. Bad answer: “Just call your primary care.” Your primary care will not be open at 11 p.m. Friday, which is exactly when the question will come.

When to Call Whom

Keep this on your phone. It is the most practical page in this article.

Call 911 right now:

• Severe bleeding that won’t stop
• Chest pain
• Difficulty breathing
• Sudden severe confusion or unresponsiveness
• Signs of stroke (facial droop, slurred speech, one-sided weakness)
• Severe allergic reaction (hives plus swelling, wheezing, throat tightness)

Call the hospital discharge line or inpatient pharmacy (first 72 hours):

• “Does this pill look right?”
• Dose clarifications on anything new
• A prescription the pharmacy can’t fill
• A new symptom that started within 24 hours of discharge

Call the primary care office (non-emergency, business hours):

• Side effects that are uncomfortable but not dangerous
• Refill coordination
• Follow-up scheduling
• Anything you want added to the medication list for the PCP to review

Call the community pharmacist:

• Side effect questions
• Drug and OTC interaction questions (cough and cold medicines, sleep aids, supplements)
• Cost or insurance issues
• Whether a bottle from the pharmacy matches the discharge list

Two of those four can be handled by a pharmacist. Pharmacists are the most accessible clinicians in American medicine, and most caregivers under-use them dramatically.

What a Hospital Discharge Pharmacist Actually Does

There is an entire clinical role whose job is to prevent everything I described above, and in many hospitals, it happens well. When it does, here is what it looks like: a pharmacist sits down with the patient and a family member before discharge, goes through every drug on the new list, compares it line-by-line to the home list, flags any duplication, interaction, or omission, teaches about any new drug (what it’s for, how to take it, what to watch for), and often calls the patient 72 hours after discharge to follow up.

I’ve written separately about what a hospital pharmacist does day-to-day. For discharge specifically: when a pharmacist is integrated into the process, the evidence base is large. BayCare Health System cut 30-day readmissions from 15.9% to 9.0% with pharmacist-led discharge reconciliation and follow-up. Bae-Shaaw and colleagues (AJHP, 2020) studied 4,745 patients with heart failure, MI, COPD, or pneumonia and found a 30-day readmission odds ratio of 0.65 with pharmacist-led transitions of care (the heart failure subgroup was 0.52). Ravn-Nielsen and colleagues (JAMA Internal Medicine, 2018) ran a randomized trial of 1,467 patients and found a readmission hazard ratio of 0.62 when an in-hospital pharmacist intervention was paired with post-discharge telephone follow-up.

That work costs roughly $101 per hospitalization. It is one of the highest-yield patient-safety interventions in modern American medicine. It is also structurally inconsistent, because the pharmacist staffing isn’t there on every unit, every day, for every patient.

A question worth asking the discharge nurse, directly: “Did a pharmacist review this discharge medication list?” If the answer is “yes, they did, here’s what they found,” you have a much safer handoff. If the answer is “no” or “I’m not sure,” you know to be the pharmacist yourself until you can get one on the phone.

The Frameworks Nobody Tells Families About (BOOST, STAAR, RED, CTI)

I’m including this section because it arms you with language the hospital responds to. Most families don’t know these exist. Mentioning one of them in a discharge conversation changes how the team answers you.

AHRQ RED (Re-Engineered Discharge). Developed at Boston University Medical Center, endorsed by IHI, The Leapfrog Group, and CMS. RED defines 12 discharge actions, including reconciling the discharge plan, identifying correct medications with a plan to obtain them, teaching in a way the patient understands, assessing understanding, and providing a post-discharge phone call within 72 hours. An Arizona QI project using RED documented a 22% readmission rate in the RED group versus 50% in the comparison group.

Project BOOST (Better Outcomes for Older Adults through Safe Transitions). Developed by the Society of Hospital Medicine. BOOST uses an 8Ps risk-assessment tool to screen for problems with medications, poor health literacy, poor social support, and other risk factors. The Beckman 11-hospital evaluation (J Hosp Med, 2013) found that BOOST reduced 30-day rehospitalization from 14.7% to 12.7% on participating units, while matched controls showed no change.

STAAR (State Action on Avoidable Rehospitalizations). IHI-led multistate collaborative. Embeds medication reconciliation across every transition. At least one academic implementation achieved a 30% reduction in readmissions over four years (Carter, BMJ Innovations, 2015).

The Coleman Care Transitions Intervention (CTI). Eric Coleman’s randomized trial (Archives of Internal Medicine, 2006) pairs patients with a transition coach and a personal health record focused on medication self-management. Coleman documented an average of 11 medication discrepancies per patient at a routine home visit, and described that figure as “unfortunately not uncommon.” CTI-enrolled patients had significantly lower 90-day readmission rates and roughly $3,752 in savings per Medicare patient.

What to do with this: ask the discharge nurse, “Does this hospital use a formal transitions program like RED or BOOST?” If the answer is yes, ask what pieces of it your parent is getting. If the answer is no, you know you’re filling that role yourself.

What I’d Do If It Were My Mom

I get asked some version of this question constantly, so I’ll answer it directly.

If my own mother were being discharged tomorrow, I would stay in the hospital room until a pharmacist had reviewed the final medication list with me in person. I would put every pre-hospital bottle on the counter the night she came home and check every drug against the new list before anyone took a dose. I would call the primary care office the next morning and schedule the 5-day follow-up. I would write the red-flag symptoms for her specific drug classes on an index card on the fridge. I would call her community pharmacist within 72 hours and ask for a full review, with the discharge list in hand. And I would watch her, specifically, for the first seven days.

This is, not coincidentally, what ManyMeds does for families who don’t have a pharmacist in the family. I go through the discharge list the way I go through a list at the hospital, compare it to what they were taking before, flag the things that don’t belong, find the things that got dropped, and give the family one clear, reconciled list plus a plain-English explanation of every change. I’m not replacing the primary care doctor. I’m doing the coordination piece that the system is structurally not built to do at home. If you want that kind of review, I do offer it privately, and you can reach me through the main site.

If you’d rather do it yourself, the medication list template I’ve built is the same format I use for hospital handoffs, with space for what changed and why. It is free.

About the author

Andrea Simon, PharmD, BCIDP, APh, is a practicing hospital pharmacist in antimicrobial stewardship at a Southern California hospital. She holds a Doctor of Pharmacy, completed residency training, is board-certified in infectious diseases pharmacy, and is licensed as an Advanced Practice Pharmacist by the California State Board of Pharmacy. She founded ManyMeds to give families access to the same medication-safety work she does in the hospital.

References

1. Forster AJ, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine / CMAJ, 2003–2004. Approximately 20% of discharged patients experienced an adverse event within three weeks; ADEs were the most common category, with roughly three-quarters judged preventable or ameliorable.
2. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network. Adverse Events After Hospital Discharge. Primer citing the Forster dataset and HHS National Action Plan for Adverse Drug Event Prevention.
3. El Morabet N, et al. Drug-related readmissions in older adults: systematic review and meta-analysis. PLOS ONE, 2021. Approximately 10% of older adults experienced a drug-related readmission; 40% of 30-day readmissions were assessed as possibly medication-related.
4. Alqenae FA, et al. Prevalence and nature of medication errors and adverse drug events among hospitalized older adults with cardiometabolic medication changes at discharge. J Gen Intern Med / related publications, 2023–2026. 39% of participants had made at least one error by 7 days post-discharge; 50% by 90 days.
5. Hawkins TM, et al. Adverse drug events and medication changes among older adults receiving oral anticoagulants after hospital discharge. CMAJ Open, 2021. Switching anticoagulant class during hospitalization doubled subsequent ADE risk; hemorrhage and thromboembolism rates peaked in the first 30 days post-discharge.
6. Lipscombe LL, et al. Short-term outcomes of new-onset diabetes medication initiated during hospitalization among older adults. J Gen Intern Med, 2019. New in-hospital insulin initiation associated with 1.59-fold higher 30-day mortality vs. prevalent oral agent users; hypoglycemia independently doubled 30-day mortality (OR 2.02).
7. Gallagher D, et al. Post-discharge discontinuation of antihyperglycemic therapy after acute myocardial infarction. Observational analysis: 13.4% of patients had antihyperglycemic therapy discontinued at discharge; discontinuation independently associated with 29% higher one-year mortality.
8. Solomon DH, et al. The comparative safety of analgesics in older adults with arthritis. Elderly opioid recipients had 1.7× higher 30-day mortality and 1.2× higher odds of any adverse effect vs. NSAID users; NNH for any ADE = 26.
9. Gerlach LB, et al. Discontinuation of antipsychotic medications after hospital discharge in two nationwide cohorts. JAMA Psychiatry, 2025. Discontinuation after discharge associated with lower rehospitalization and lower all-cause mortality, consistent across age, sex, and dementia status.
10. Flurie RW, et al. Atypical antipsychotic continuation after ICU initiation: multicenter analysis. 23% of ICU atypical antipsychotic starts continued after hospital discharge.
11. Herzig SJ, et al. Antipsychotic prescribing among non-psychiatric inpatients and discharge continuation. 4% of non-psychiatric inpatients newly initiated on an antipsychotic were discharged on the drug.
12. Proton pump inhibitor continuation after ICU discharge. Mayo Clinic Proceedings, 2020. Approximately 1 in 6 ICU PPI starts inappropriately continued at hospital discharge; unnecessary continuation associated with 27% increased pneumonia risk.
13. Benzodiazepine continuation after hospitalization in older adults. 15% of older adults continued benzodiazepines for 2 or more months after a hospital stay; STOPP criteria recommend against ≥4-week use.
14. American Geriatrics Society 2023 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Strong recommendation to avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options have failed; muscle relaxants and benzodiazepines on the avoid list.
15. Chhabra PT, et al. Medication reconciliation in critically ill older adults: prevalence and severity of discrepancies. 96% of discharge-stage discrepancies in older adults were omissions; patients with unintentional discrepancies had twofold higher risk of ED visits within 30 days.
16. Viktil KK, Blix HS, et al. Pharmacist-led discharge medication reconciliation: multisite study. 41% of patients who received admission medication reconciliation did not receive discharge medication reconciliation; primarily due to pharmacist not being notified of discharge.
17. BayCare Health System pharmacist-led discharge reconciliation pilot. 30-day readmission rate reduced from 15.9% to 9.0% with integrated pharmacist review and 72-hour follow-up.
18. Bae-Shaaw YH, et al. Real-world evidence of a pharmacist-led transitions-of-care program on 30-day readmissions. American Journal of Health-System Pharmacy, 2020. n = 4,745; 30-day readmission OR 0.65; heart failure subgroup OR 0.52.
19. Ravn-Nielsen LV, et al. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission. JAMA Internal Medicine, 2018;178(3):375–382. n = 1,467; readmission HR 0.62 (95% CI 0.46–0.84).
20. Nuckols TK, et al. Economic evaluation of pharmacist-led transitions-of-care services. Hospital Pharmacy, 2023. Comprehensive pharmacist-led transitions service cost approximately $101 per hospitalization.
21. Bracey A, et al. Teach-back and patient recall of discharge instructions. Joint Commission Journal on Quality and Patient Safety, 2023. Only 50% of patients correctly recalled post-discharge treatment plans and 43% correctly recalled their medication changes.
22. Choudhry AJ, et al. Readability of trauma discharge summaries. American Journal of Surgery, 2016. Mean 10th-grade reading level; 24% of patients had the literacy to fully understand their discharge documentation; 65% of those readmitted within 30 days lacked the literacy to understand discharge instructions.
23. Coleman EA, et al. The Care Transitions Intervention: a randomized controlled trial. Archives of Internal Medicine, 2006;166(17):1822–1828. CTI-enrolled patients had significantly lower 90-day readmissions; average of 11 medication discrepancies identified per home visit.
24. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine, 2013;8(8):421–427. BOOST reduced 30-day rehospitalization on participating units from 14.7% to 12.7%; matched controls showed no change.
25. Carter J, et al. State Action on Avoidable Rehospitalizations (STAAR). BMJ Innovations, 2015. Multistate implementation; at least one site achieved a 30% reduction in readmissions over four years.
26. Jack BW, et al. A reengineered hospital discharge program to decrease rehospitalization. Annals of Internal Medicine, 2009; AHRQ Re-Engineered Discharge (RED) Toolkit, 2012. 12 discharge components including 72-hour post-discharge phone call; endorsed by IHI, The Leapfrog Group, and CMS.
27. The Joint Commission. National Patient Safety Goal NPSG.03.06.01: Medication Reconciliation. Requires reconciliation at every transition of care.
28. American Society of Health-System Pharmacists (ASHP) and American Pharmacists Association (APhA). Medication Management in Care Transitions Best Practices. Pharmacist counseling at discharge and follow-up calls at 72 hours and within 30 days.
29. Hesselink G, et al. Improving patient handovers from hospital to primary care: systematic review. Discharge summaries are poorly transferred and frequently arrive at the primary care office after the follow-up visit.

Where the original first author was not named in source material, the citation reflects the journal, year, and headline finding as published. Primary literature resolves via PubMed, AHRQ PSNet, CMS, The Joint Commission, and the American Society of Health-System Pharmacists.