Improving Patient Care With Medication Management

Our guide on medication management provides valuable tips and tools that can elevate the performance of any medication management program. Read the guide below or enter your email to download your copy to take on the go.

Improve Medication Management


Not many days pass without new reports of frightening stories on medication errors that could — and should — have been avoided. In a best-case scenario, patients manage to escape no worse for wear, the error is identified, and steps are taken to reduce the likelihood of the error happening again. But concerning medication errors, the best-case scenario is often not the actual scenario. Medication errors frequently lead to significant harm to patients and are caused by systemic flaws that may not have simple solutions.

Statistics reveal the danger and frequency of medication errors:

Medical Errors


Deaths caused by medical errors per year

Percent of Adults


Of adults have experienced a medical error

Estimated Annual Cost

$17.1 billion

The estimated annual cost of measurable medical errors that harmed patients in 2008

Hospital Medical Error

1 in 7

Medicare patients experience a medical error in hospitals


1 in 10

Doctors reported a major medical error

Newly Graduated Nurse Errors


The percentage of medical errors that involve newly graduated registered nurses with less than a year of experience in patient care.

These figures demonstrate just how important it is for payers and providers to prioritize medication management. This eBook is designed to help you develop a new medication management program or improve an existing program. It includes guidance on an extensive range of medication management-related matters and provides valuable tips and tools that can elevate the performance of medication management programs.

When a medication management program is firing on all cylinders, the benefits are evident and significant, including reduced readmissions and medical costs, improved quality ratings (e.g., Medicare Stars, HEDIS), increased patient safety, and greater achievement of health goals. Leverage the resources in this eBook as part of your ongoing efforts to enhance the overall delivery of care for patients and members. Even the smallest of improvements is likely to have wide-reaching, positive clinical and financial effects.

Improved Quality Ratings


What is Medication Management?

Chapter 1

What is Medication Management?

There’s no question that medications are incredibly important for treating patients with acute and chronic conditions. However, with approximately 50% of patients taking medications incorrectly, it’s vital that hospitals and clinicians consistently follow best practices. This helps ensure patients take their medications the right way so their health can improve or, at the very least, they can better manage their condition.

Medication management is a service to help patients manage their medications so they take them as prescribed, and avoid the adverse effects associated with incorrect medication administration.

Some best medication management practices to consider implementing in your facility include the following:

  • Perform medication reconciliation at every patient encounter and during care transitions
  • Engage patients
  • Ensure comprehensive discharge planning, including providing medication reconciliation post-discharge (MRP)
  • Schedule a prompt follow-up appointment to reconcile and discuss medications and regimen changes, leveraging the expertise of clinical pharmacists, when appropriate
  • Proactively follow up with high-risk patients
  • Perform drug therapy monitoring
  • Use motivational interviewing and other communication techniques
  • Update guidelines for prescribing opioids to reflect current recommendations

Medication Adherence

A critical aspect of successful medication management is medication adherence. If patients are failing to take their medication as directed, the medication management process loses significant value.

To put patients in the best possible position for successful medication adherence, here are a few tips to follow:

  • Provide education and training on medication adherence
  • Give resources to support adherence efforts, including during transitions of care (e.g., discharge)
  • Allocate time for patient engagement
  • Require documentation of adherence discussions
  • Invest in helpful technology
With medication adherence measures included in CMS star ratings and HEDIS®, among other quality ratings and scores, providers and payers will want to target this area as a component of care for improvement.

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Additional Reading:

The Role of Medication Adherence in Medication Management

To put your clinicians in a better position to help patients improve adherence, follow these tips.

Importance of Patient Education and Adherence

Chapter 2

Importance of Patient Education and Adherence

Importance of Medication Education

Statistics show that every minute, around three Americans call a poison control center because they’ve made a mistake with their medication. Patient education is vital to reduce the frequency of these errors.

There are a few key areas to focus on when sharing vital information about medications:

  • Medication's purpose
  • Desired effects and possible side effects
  • Medication name and qualities (e.g., type, color, shape)
  • Instructions for proper use
  • Warnings
  • Responding to side effects
  • Importance of asking questions
  • Value of transparency concerning medication history

Furthermore, make sure patients understand the crucial role they play in their own care. While education is of the utmost importance if a patient doesn’t understand how to put that knowledge into action, your efforts to help them will likely come up short.

Patient Medication Management

Clinicians help patients in a number of ways, including diagnosing conditions, providing treatments, recommending services, and prescribing medications. However, clinicians can only do so much when it comes to the action that patients actually take, which is the case with medication management.

To support patients, clinicians can positively influence decisions regarding patient medication management. A few reasons patients often struggle with adherence include:

Low health literacy

This is the capacity for individuals to obtain, process, and understand the basic health information and services required to make proper health decisions. Clinicians should be prepared to assess their patients’ health literacy and support patients with lower literacy using different resources when applicable.


Believe it or not, cost is the most common reason prescriptions go unfilled. Financial challenges often lead patients to delay or skip refilling medications or even rationing medication, which can prove dangerous. It’s for these reasons clinicians should discuss finances with their patients and provide information about how patients can obtain financial assistance, order medications by mail, and take other steps to aid in patients obtaining and affording the medications they need.


Another reason patients often struggle with adherence is a lack of understanding of their prescriptions. This may include the purpose of medication, why it’s necessary, side effects, and how long the medication takes to work. Clinicians must take the time to discuss each medication and the medication’s qualities with patients.


Finally, fear of side effects may also prevent patients from taking or even filling their prescriptions. Clinicians can work to prevent these adherence obstacles by discussing all side effects with patients, and any concerns patients may have with following their medication regimen.

Medication Management Activities

Taking education and medication adherence one step further, there are medication management activities that can support your efforts to help patients stick with their medication regimen.

  1. Ask patients to bring all of their medications with them to each appointment or at least bring a detailed list of their medications, including name, dosage, and regimen. Taking photos of the prescription label using a smartphone may be useful.

  2. When reminding patients about appointments, also remind them to bring their medications or provide a list or photos, as detailed above.

  3. Provide patients with a current medication list at the end of each visit.

  4. Explain the benefits of pharmacy “pill packs” and provide a list of service providers.

  5. Suggest that patients use an automated pill reminder app.

  6. Encourage patients to use a medication synchronization service.

  7. Distribute and display a medication fact sheet in the office.

  8. Improve staff training and provide guidance to all staff about how to speak with patients and families about the importance of taking medicines as prescribed.

  9. Following discharge and during other transitions of care, connect patients with clinical pharmacists who can provide comprehensive medication management services, including MRP, and support

Medication Management for Seniors

Finally, we can’t move on from this section until we address an important and particularly vulnerable segment of patients: seniors. Adults 65 and older are at greater risk for medication-related problems. Three main reasons: 1) They are more likely to take multiple medications; 2) They’re more susceptible to side effects; and 3) They are at a higher risk of drug interactions.

While the best practices we’ve already covered can apply to this age group, there are a few additional steps clinicians can take to improve success concerning medication management for seniors

Focus on education

Before even discussing a medication, clinicians should ensure that patients can properly manage their medication regimen. This might require addressing obstacles such as poor health literacy, declining memory and eyesight, language barriers, and financial stability. Once you’ve determined if there are any potential obstacles, review information such as the medication’s purpose, how the medication should be taken, possible side effects, and other key details.

Make it a priority to discuss cost

Cost is increasingly becoming a medication adherence barrier for seniors. Since many seniors live on a tight budget and fixed income, the affordability of prescriptions may hinder medication adherence. Economic instability can force patients to make difficult decisions about their medications, which points to the importance of understanding and factoring in social determinants of health (SDoH) when building a medication management program.

Reduce complexity

Seniors also tend to take more medications, which increases the complexity of their regimen. When possible, reduce the number of medications and their administration frequency. (Note: Learn more about polypharmacy here.)

Provide and recommend resources

While verbal instructions can prove helpful, this type of communication also leaves room for error. As much as possible, clinicians should provide patients with a written list of all current medications and their accompanying information, in addition to other resources that can aid in adherence.

Leverage technology

While not all seniors will be comfortable with or even use smart technology, clinicians should take advantage of those that do. A 2021 Pew Research Center survey showed that more than 60% of U.S. adults 65-plus years of age owned a smartphone, so there is an opportunity to effectively leverage this technology comfort level. If your patient is tech-savvy, recommend a medication adherence app that can improve their medication management.

Conduct regular medication reviews

Make sure to review senior patients’ medications regularly. As a patient’s conditions change, a medication prescribed in the past might not be the best option even just a few months later.

Prioritize MRP

Finally, ensure these high-risk patients consistently receive medication reconciliation post-discharge (MRP). Clinical pharmacists, like those with the Cureatr Clinic, bring the knowledge and trustworthiness to support seniors during transitions of care effectively.

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Safety in Hospitals

Chapter 3

Safety in Hospitals

Medication management presents a number of challenges in a hospital setting that can contribute to readmissions. However, when steps are taken to improve the medication management process, hospitals can ultimately reduce medication-related readmissions and ED visits. There are many complexities to consider and overcome in order to accomplish this important objective. Let’s explore a few major challenges. 

Patient Financial Constraints

One in four Americans report difficulty affording their prescription drugs, and one in eight say that they or a family member have rationed doses due to high costs. So, for many patients, you must be aware of how cost could affect their ability even to fill a prescription, let alone take it correctly.

Medication Costs

Not only do patients struggle with medication costs, but hospitals also do as well. Rising costs are straining hospital budgets, leading some hospitals to pursue alternative medication therapies to control costs better. Such financial stress can prevent hospitals from making the best clinical decisions and providing the highest quality of care.

Drug Shortages

A national survey of pharmacists found that nearly all pharmacists were seeing the impact of drug shortages on healthcare delivery. Such shortages, which can also contribute to rising medication costs, may require hospitals to make difficult medication-related decisions, such as finding substitute medications, conserving supplies, producing their own medications in a compounding pharmacy, and determining which patients need medication right away and which patients can safely have treatment delayed. 

Safety Risks

Medication errors that occur in hospitals present safety risks for patients. While not all mistakes cause harm, many can lead to injury or even death. The challenge is that so many factors can cause a medication error, making it difficult to determine the best ways to prevent mistakes.

Incomplete Patient Medication Histories

To provide the best medication management, clinicians must have access to a patient’s comprehensive medication history. If even one detail of a patient’s medication history is omitted, this could lead to an adverse event.

Care Transition Breakdowns

With every transition between doctors, departments, or facilities, there’s potential for a breakdown to occur. For example, a breakdown can occur if a patient has limited English proficiency or low health literacy and does not follow their treatment plan correctly or a patient or caregiver is excluded from transition planning. These potential breakdowns further point to the importance of providing patients with medication reconciliation post-discharge.

Opioid Prescribing

A newer challenge that has emerged in recent years concerns prescribing opioids. This issue requires clinicians to carefully differentiate which patients are showing drug-seeking behavior, which is planning to sell the drugs and those that actually require an opioid prescription.

Importance of Medication Safety

To help keep patients safe from the challenges noted above, there are several steps organizations can take to protect patients from errors

  1. Be consistent about medication reconciliation, including MRP

  2. Encourage patients to participate in medication reconciliation

  3. Ask granular questions about over-the-counter medicines and supplements

  4. Make drug reference tools handy for clinical teams

  5. Engage clinical pharmacists

  6. Follow up with patients during transitions of care, such as after discharge and office visits

  7. Encourage older patients to bring an advocate

Boosting Quality Ratings With Improved Medication Management and Safety

Efforts to improve medication management and safety will benefit more than just patients. Better performance concerning various medication-related processes can also strengthen payers’ and providers’ quality ratings.

For example, the Healthcare Effectiveness Data and Information Set (HEDIS®), developed by the National Committee for Quality Assurance (NCQA), includes several measures for health plans that directly or indirectly speak to medication management and safety. Among them:

  • Deprescribing of Benzodiazepines in Older Adults (DBO). Its description is as follows: “The percentage of members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose (diazepam milligram equivalent [DME] dose) during the measurement year.” While many quality measures focus on increasing or increasing the rate of something, the DBO HEDIS® measure is unique in that it measures a decrease.

  • Transitions of Care (TRC). One of the four reported rates for the TRC HEDIS® measure is medication reconciliation post-discharge. NCQA describes the MRP indicator as “Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).” As we wrote in this blog post, the inclusion of MRP within the Transitions of Care HEDIS® measure would suggest that “medication management, and medication reconciliation in general, has a much greater role to play in care coordination and the overall health of patients.”

  • Advance Care Planning (ACP). In describing the intent of this HEDIS® measure, the NCQA states, “Advance care planning is associated with improved quality of life, increased provider trust, and decreased hospitalization. This measure will allow plans to understand if advance care planning is provided to beneficiaries who are most likely to benefit from it.” Medications undoubtedly place a crucial role in advance care planning. A proper plan will include current information about a patient’s medications and their purposes, and medication management should be a topic of discussion during the development of the advance directive.

TRC, MRP, and medication adherence are also crucial for payers looking to improve or maintain their Medicare star ratings performance.

On the provider side, transitions of care, MRP, and medication adherence all play vital roles in helping avoid medication-related complications. Such complications can lead to a significant concern for providers: readmissions.

Poor or increasing readmission rates can greatly impact a hospital’s quality star rating. Gregory Downing, DO, Ph.D., states: “If a hospital experiences a significant increase in readmissions year over year, and generally the star ratings look at three-year time blocks, then CMS could decrease a percentage of its payment to the hospital for subsequent years.”

He goes on to note that focusing on medication management is proven to help improve Medicare star ratings. “We have worked with a hospital system that went from 4 stars to 5 this past year,” Dr. Downing said. “One of the major contributing factors was a care coordination program that reduced readmissions with the help of improved medication management.”

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Additional Reading:

Importance of Medication Safety: How to Protect Patients

Learn the 7 steps organizations can take to protect patients from the danger of medication errors.

Importance of Medication Administration, Drug Interactions, and Opioid Pain Management

Chapter 4

Importance of Medication Administration, Drug Interactions, and Opioid Pain Management

Importance of Medication Administration

Another key aspect of medication management is ensuring that medications are administered safely and accurately. As evidenced by the fact that the median error rate of medication administration is 8% - 25%, consider ways you can improve medication administration in your facility. 

  1. Assess the work environment

    Mistakes and other safety issues can increase due to certain work conditions. These include staff shortages or turnover, staff distractions or interruptions, poorly designed medication safety protocols, and failure by staff to adhere to policies and guidelines. It is vital to evaluate each of these areas mentioned on a regular basis and make changes as needed.

  2. Implement medication safety technologies

    There are a number of technologies that can improve medication safety, including medication safety alerts, medication and patient barcoding, smart infusion pumps for intravenous (IV) administration, and single-use medication packages. While technology can prove helpful, effective use requires careful oversight and training.

  3. Educate patients and caregivers

    Since many medication administration problems occur due to patient or caregiver error, this is an area providers cannot afford to ignore. Provide patients and/or caregivers with the necessary education, including how to properly take medications at home and when to contact their provider if they aren’t sure how to administer it or have other questions.

  4. Implement strategies for “LASA” drugs

    When patients are prescribed a look-alike and/or sound-alike (LASA) drug, there is major potential for an error to occur. This can happen whether the names, packaging, or administration device are similar. Fortunately, there are a few ways that clinicians can work to avoid errors due to LASA drugs, including the following:

    Use “tall-man lettering
    Add warning labels to alert staff
    Educate patients and caregivers about these types of drugs
    Configure your computerized order entry system to alert  clinicians when they are prescribing a LASA drug

  5. Take extra precaution with “high-alert” medications

    Finally, take additional precautions when it comes to medications that are more likely to cause harm or death when used in error. According to the Institute for Safe Medication Practices (ISMP), five of the top high-alert medications are insulin, opiates and narcotics, injectable potassium chloride (or phosphate) concentrate, IV anticoagulants (heparin), and sodium chloride solutions above 0.9%.

Importance of Drug Interactions

As mentioned in the previous section, educating patients and caregivers can help prevent medication errors. Discuss each of these areas related to drug interactions with your patients and caregivers:

  • Drug interaction risks 
  • Types of drug interaction risks
  • Patient-specific risks
  • Medication labels
  • Supplements
  • Responding to a drug interaction

Opioid Pain Management

One specific area of medication management that should not be overlooked is opioid pain management. As a serious problem on the rise, opioids claimed more than 68,000 lives in 2020.

While healthcare organizations should be aware of opioid-related dangers, many patients still require these opioids to manage their pain effectively.

Here are a few initiatives the healthcare industry is undertaking to better manage opioid pain management:

  1. CMS Roadmap

    The Centers for Medicare & Medicaid Services (CMS) recently took an official stance on the opioid crisis and published a piece to address three key components: prevention, treatment, and data.

  2. Organizations review and update prescribing guidelines

    Many healthcare organizations are reviewing and updating guidelines for managing acute and chronic pain, which includes using technology to alert clinicians about risk issues and prescribing behavior. For example, Kaiser Permanente Southern California, began working to reduce the inappropriate use of opioids in 2010.

    A few steps the organization took were creating restrictions, implementing monitoring technology, and providing clinicians with guidance for prescribing and formulary policies. The organization has reduced its prescribing of the highest-risk, long-acting opioid medications for non-cancer, non-hospice patients by more than 72% and high-volume prescriptions of short-acting opioids by 98%.

  3. Training courses focused on best practices and alternatives

    In 2019, an estimated 10.1 million people misused prescription opioids — putting them at risk for dependence and addiction. Organizations must train clinicians with methods and tactics that can prevent additional medication therapy-related risks and medication abuse for patients.

  4. Prescription drug monitoring programs (PDMPs)

    PDMPs are valuable tools. State-based electronic databases track the prescribing and dispensing of controlled substances. With 49 states and the District of Columbia using PDMPs, these systems have effectively contributed to the reduction in opioid prescriptions by 8% and prescription opioid overdose death rates by 12%.

  5. New technologies for improving medication history

    Knowing a patient’s medication history is a crucial part of opioid pain management. However, this information is not always easy to obtain from patients or other healthcare organizations. A technology platform such as Meds 360°, which is used by the clinical pharmacists at Cureatr Clinic, provides access to current medication lists in real-time, delivering an accurate view of any potential risks related to opioids.

  6. Forming of coalitions

    Finally, healthcare organizations recognize the need to work together with county health departments, providers, payers, and community groups toward the common goal of addressing prescription drug abuse within the community, which is leading to the formation of collaborative coalitions.

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How Patient Care Coordination Improves Medication Reconciliation

How Patient Care Coordination Improves Medication Reconciliation

Bringing about positive changes to the components of effective care coordination will ultimately help ensure a more successful med rec process.

Developing an Effective Medication Management Process

Chapter 5

Developing an Effective Medication Management Process

Medication Management Care Plan

A successful medication management care plan hinges upon collaboration with the patient. Here are some steps you can take to improve the effectiveness of the care plan.

  1. Perform a drug inventory —

    A trained clinical staff member should conduct a review of each prescription, over-the-counter medicine, vitamin, and herbal remedy with the patient. For each medication, this staff member should document the name, reason for taking it, dosage, frequency, the correct time to take it, and any special instructions. 

  2. Assess effectiveness, adherence, safety, and cost —

    Once the inventory is complete, a physician, mid-level provider, or registered nurse should speak with the patient about any reasons they may have for not taking medications and potential obstacles to adherence, such as cost. 

  3. Discuss at-home medication organization —

    Discuss how a patient is keeping prescriptions organized at home. This is particularly important for patients with limited dexterity, cognitive impairment, or mobility issues. Discussion topics may include asking patients if they have a pill tray, how they remember which pill goes in each section, and if anyone double-checks the filled pill tray.

  4. Help the patient create or refine the medication regimen —

    Since creating an effective medication regimen can be challenging, address any issues patients might have with their routine. For example, if a patient routinely forgets to take pills, ask why. Reasons might include leaving home without medications or falling asleep before their final dosage of the day.

  5. Encourage the use of individualized, multi-dose drug dispensing (MDD) —

    For patients that struggle to remember if they took their medication or are unsure which medications to take, the use of MDD may be a good option. Some pharmacies can dispense an MDD pack that includes all the patient’s daily medicines in tear strip bags or bubble packs as opposed to single prescription bottles.

Medication Management Services

As you prioritize improving medication management in your organization, you can help patients with adherence by offering these services.

Medication Therapy Review

This is defined by the American Pharmacists Association as the:

“Systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them.”

This review not only sets a solid foundation for future success with medication management but also allows you to make appropriate medication decisions for patients and provides the most effective guidance. 

Comprehensive Medication Analysis

To assemble a comprehensive understanding of a patient’s medications, there is a lot of information to digest, including the names of medications, what they do, when they are taken, and side effects. Beyond this, there may also be non-prescription medications, herbals, supplements, and vitamins to consider.

A thorough, face-to-face discussion with the patient is critical for reviewing all medications, answering questions, and discussing potential ways to improve management, such as using a written medication plan, pill organizer, and/or mobile app.

Collaboration With Clinical Pharmacists

Patients and caregivers can receive support from clinical pharmacists. For example, Cureatr’s Virtual Pharmacy Clinic partners with health plans to provide patients with direct access to board-certified clinical pharmacists. These clinical pharmacists improve care coordination, help patients achieve treatment goals, and reduce avoidable readmissions by better ensuring the most effective and appropriate use of medications.

New Medication Education

One of reasons patients do not take new medications is “misunderstanding.” For this reason, you must take the time to discuss with the patient the new prescription, explain why it’s important, the roles the drug plays in overall care, instructions, side effects, and any questions.

Identify and Recommend Generics

If you identify and prescribe a generic medication, make sure your patient is aware so they can ensure that the correct medication is filled at the pharmacy. Prescribing a generic can help ease the financial barrier to filling and taking their medication as prescribed.

A few ways for clinicians to identify if a generic version of a medication exists includes the following:

Provide Education on Pharmacy Services

Finally, services offered by pharmacies can offer an additional means of supporting patients with medication management and adherence. A few helpful services that may be available include:

  • Text alerts and refill reminders
  • Automatic refill
  • Medication synchronization to align prescription fill dates
  • Shipping of prescriptions
  • Rewards system (a gamification technique)
  • Mobile apps that can help with arranging pickup, payment, and prescription renewals

Medication Management Goals

Whether you’re working to evaluate your medication management process or building a comprehensive medication management process from scratch, it’s helpful to establish goals to serve as guidelines. Here are some worth considering. 


Improve Patient Education —

Patients fail to follow medication regimens for many reasons, including fear, misunderstanding, cost, and worry. Each of these problems can be solved by improving patient education.

Doing so might require assessing your organization’s current education approach and effectiveness. Education should cover any potential areas that could prevent patients from following their medication plan, including side effects, cost challenges, obstacles to filling or refilling prescriptions, and failing to follow a schedule, as well as steps to take if they have questions or concerns about their medication. Make sure patients receive timely education about their medications, including during transitions of care.

Improve Patient Education

Reduce Medication Errors —

While every organization should set a goal of zero medication errors, it may be more reasonable to start by setting achievable goals to reduce the number of medication errors each month, quarter, and year.

To help reach your goals, perform a comprehensive root cause analysis when a medication error and adverse drug event occurs. Using the results from this analysis, you can determine changes that need to be made and measure if the changes you make are preventing medication errors from occurring.

Reduce Medication Errors

Strengthen Follow-Up Processes —

Set a goal for a follow-up plan whenever a patient leaves a hospital or doctor’s office. This will ideally be in the form of medication reconciliation post-discharge, when beneficial, and a follow-up appointment with a primary care practitioner (PCP). Research shows about 53% of all discharged patients are sent home with at least one medication error, while a study showed that “patients lacking timely PCP follow-up were ten times more likely to be readmitted for the same condition within 30 days of hospital discharge and nearly seven times as likely to be readmitted for the same condition or receive other care.”

Such follow-up support can ultimately serve to:

  • Review medication regimen
  • Identify and address medication errors
  • Close quality gaps
  • Account for social determinants of health
  • Catch signs indicative of non-adherence
  • Provide education
  • Answer patient questions
Strengthen Follow-Up Processes

Medication Management Goals

Now that we’ve covered how to put together a plan, medication management services, and goals for your organization, what’s left is improving the medication management process as a whole. Here are a few tips for strengthening various elements of the process.

  1. Educate patients about common medication mistakes

  2. Deprescribe unnecessary medications when possible 

  3. Watch for the “prescription cascade”

  4. Ensure appropriate patients receive medication reconciliation post-discharge 

  5. Suggest reminder and organization tools that are most comfortable for patients

  6. Always take social determinants of health into consideration 

  7. Talk about adherence at every visit and during care transitions

  8. Add clinical pharmacists to your care team 


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Additional Reading:

8 Tips for the Medication Management Process

The medication management process includes initial and ongoing medication review to address safety and adherence concerns, reduce adverse drug events, educate patients, and more.

Staff Training, Tips, and Tools

Chapter 6

Staff Training, Tips, and Tools

Safe Medication Management

Just as crucial as the software you have in place is ensuring that you train staff in safe medication management. Here are a few guidelines to follow:

  1. Be on alert for high-alert medications —

    High-alert medications are defined by the Institute for Safe Medication Practices (ISMP) as:
    “Drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.”
    While ISMP provides a standard list of these medications, it’s a good idea to revise the list according to the medications your facility frequently uses. With this list, you can train staff about the dangers of these drugs and also teach them how to most effectively educate patients about these medications.

  2. Watch out for look-alike/sound-alike (LASA) medications —

    Training your staff on these medications can help save lives for medications with similar appearances or names. By maintaining a list of these medications and educating staff about them, you can reduce potential errors by:

    Avoiding the use of abbreviations
    Using tall-man lettering to help distinguish medications
    Limiting access to these medications
    Using warning flags in computer systems
    Storing LASA medications in different locations

  3. Don’t cut corners on storage —

    The physical storage of medications is another important aspect to consider. This includes security, safety, safe handling, integrity, and distribution. To avoid issues related to these areas, organizations should ensure that storage rules are detailed, and staff are trained to follow each of the instructions. Tips for proper storage include:

    Develop policies for all aspects of storage
    Use standardized order sets
    Decrease availability of floor-stock medications
    Restrict access to high-alert medications
    Follow manufacturers' instructions for storing medications
    Encourage staff reporting of storage errors; use reports as learning and teaching opportunities.
    Focus on the emergency department as it is often busy and fast-paced

  4. Maintain ongoing monitoring of medications —

    Ongoing monitoring can also prevent potential safety risks with medication management. Every organization should have a system and schedule in place that can identify potential safety risks, such as:

    Expired medications
    Medications passed their beyond-use dates
    Low stock
    Inadequate storage space
    Poor organization
    Compromised security
    Compromised medication integrity
    Poor labeling
    No distinct separation of LASA drugs
    Mixing of controlled substances, high-alert drugs, vaccines, and samples with other medications

Medication Management Tips

Improved medication management ensures that patients receive the maximum benefits from their prescriptions and organizations reduce not only admissions but also increase savings. 

Here are a few tips to help patients with medication management:

  1. Understand obstacles for effective comprehensive medication management 

  2. Assess the individual needs of each patient 

  3. Be prepared with resources 

  4. Ensure adequate support during transitions of care

  5. Follow up with patients

Medication Management Tools

While training your staff and following best practices for medication management, it’s also helpful to put tools in place to support your organization’s efforts. Consider these medication management tools:


Electronic prescribing of controlled substances —

The use of e-prescribing for controlled substances can enhance patient safety. E-prescribing can help clinicians identify potential issues, such as duplicate therapies, interactions, and allergies; prevent mistakes associated with sound-alike drugs; and improve adherence.
Electronic prescribing of controlled substances

Bar-coded medication administration (BCMA) systems —

BCMA systems allow users to electronically document medications at the point of care. Using a handheld device, clinicians scan the barcode on their identification badge, the patient’s wristband, and the medication package. This allows the system to determine whether the medication scanned is correct for the patient.
Bar-coded medication administration systems

Medication safety self-assessment for hospitals —

This tool allows organizations to assess the safety of medication practices in their facilities and identify areas for improvement.
Medication safety self-assessment for hospitals

Medication reconciliation solutions —

Finally, seek out a medication reconciliation tool that provides all physicians, nurses, and pharmacists access to a complete list of a patient’s medications. Meds 360°, used by Cureatr Clinic’s clinical pharmacists,  provides a clear medication history, which supports better medication management decisions and effective medication reconciliation.
Medication reconciliation solutions


Within this eBook, we have provided you with numerous best practices and resources. Some will be easy to implement and integrate. Others will require more work and substantial coordination between various stakeholders. But all can help you develop the foundation for a successful comprehensive medication management program or take your current program to higher levels of safety, effectiveness, and quality ratings performance.

As you set out to build or strengthen your program, perform continuous monitoring and evaluation. This will help ensure that the policies and processes you implement achieve their desired results. This should also help you identify problems and inefficiencies that can be fixed and opportunities for positive changes. Engage all stakeholders — including patients and their caregivers, where applicable — for feedback on your efforts and suggestions for improvement. Even the best medication management programs have room for growth.

Finally, and perhaps most important, is to learn from every single medication error made. Mistakes happen; that is a given. What isn’t is that similar mistakes must happen again and again. That’s where the importance of a non-punitive culture comes in. With such a culture, team members are encouraged to acknowledge and raise awareness of errors, including their own. In most cases, rather than face punishment for making a mistake, staff are empowered to help assess the error and determine its root cause(s). Staff are further engaged to support efforts to strengthen systems and processes to best ensure that the same error is not repeated — by themselves or any other member of the team.

When an organization strives to learn from its shortcomings and places an emphasis on accountability and process improvement, its programs — including medication management — grow stronger by the day. And that means patient care will as well.

Improving Patient Care and Quality Ratings With Medication Management

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