Transitions in healthcare—like coming home from the hospital or moving to a rehab facility—are some of the most vulnerable moments for our aging loved ones. One of the biggest risks, medication mistakes or errors. As nurse advocates, we’ve seen firsthand how easily these mistakes can happen and how dangerous they can be. But the good news? With a little knowledge and advocacy, you can help prevent them.

Why Are Medication Mistakes So Common During Transitions?

When someone is discharged from the hospital or nursing home, there are often multiple people involved in their care: hospitalists, specialists, primary care providers, and pharmacists. Everyone handles a piece of the puzzle, but sometimes the pieces don’t fit together perfectly. Medication lists change, new prescriptions are added, old ones are stopped, and dosages are adjusted—sometimes even in the final hour before discharge.

Communication gaps are common. Discharge summaries might not be complete, and follow-up doctors may not have the latest information. Medication lists sent to the next care setting can be outdated, leading to dangerous duplications or omissions.

For older adults—especially those with complex health needs—these mistakes can have serious, even life-threatening consequences.

Read on for practical, nurse-approved strategies every caregiver and family should know to keep loved ones safe during care transitions. Don’t miss these 3 must-do tips to avoid medication mistakes and empower yourself at every step!

A Real Story: Advocacy in Action

To show you exactly how this plays out in real life, I want to share a story from my own experience as a nurse advocate. This is a true story, and it’s a perfect example of why speaking up matters.

Mary is 85 years old. She was admitted to the hospital with a diagnosis of congestive heart failure, along with a few other health concerns all making each other worse. While she was there, her cardiologist decided to start her on a new medication to help manage her heart condition. At the same time, her other blood pressure medications were discontinued. That’s a pretty common scenario—new diagnosis, new medications, changes to the old ones.

A few days into her hospital stay, something concerning happened: Mary’s blood pressure dropped dangerously low. The care team quickly stopped the new medication and had to intervene to bring her blood pressure back up. Once things stabilized, they restarted her original blood pressure medication—the one she’d been tolerating well before her hospitalization.

Fast forward to her discharge. Mary went home, and we attended her follow-up appointment with her cardiologist virtually via speaker on her cell phone. Here’s where things got tricky: The cardiologist wanted to put her back on that new medication, insisting that it wasn’t the cause of her low blood pressure in the hospital. He believed it was actually the old medication that was to blame.

But here’s what he missed: He didn’t realize that her old medication had been stopped when the new one was started in the hospital. He saw it still listed in her records and assumed she’d been taking both at the same time—when in reality, she hadn’t.

I strongly disagreed with his assessment and asked him to review the hospital notes. After a bit of back-and-forth, he reluctantly agreed to hold off re-starting the new medication.— for now. He said we would pick up the conversation on her next appointment.  Mary was understandably scared to try the new medication again, and after our discussion, the cardiologist agreed to hold off on restarting it. This could easily have been a medication mistake!

3 Nurse-Approved Strategies to Avoid Medication Mistakes

1. Always Get an Up-to-Date Medication List—Every Time

Before your loved one leaves the hospital or nursing home, ask for a fresh, updated medication list. It is not uncommon for the medication list to be changed within the hour of discharge let alone the day before. Ask if this is the most up to date list.This should include:

• Every current medication (name, dose, frequency, and what it’s for)
• Anything that’s been stopped or changed, and the reason why
• Any new medications and their purpose

Bring this list to every follow-up appointment, and share it with every doctor and pharmacist involved in your loved one’s care. Don’t assume everyone is on the same page—sometimes, you have to be the connector.

Pro Tip: Ask, “When was this list last updated?” and “Are there any changes since this morning?” Medication lists can change right up to the moment of discharge! Often the nursing home uses the doctor’s discharge summary as their orders for care. If the discharge summary is incorrect the care including medications might also be incorrect.

Oftentimes the discharge planner, case manager, or social worker sends the discharge summary as soon as possible so the nursing home can get prepared and make sure the medications will be there. Changes can occur right up until the time your loved one leaves the hospital. We need to be sure the nursing or assisted living or going home has the most up to date and current instructions for care and medications.

Pro Tip:  Make sure before you leave the hospital that they give the medications your loved one needs. Often the nursing homes or assisted living facilities will not get the medications delivered to them until the evening.  Mary missed her afternoon doses of her medications because she didn’t get them before she left the hospital and the nursing home wasn’t getting her medications delivered until later in the evening. 

2. Schedule a Medication Review with a Pharmacist or Primary Care Provider

Within a week of discharge, make an appointment with your loved one’s primary care provider or a trusted pharmacist for a medication review. Ask them to:

• Double-check for duplicates or dangerous drug interactions. Oftentimes you may see a generic name and then a repeated medication with the trade or common name.
• Review the necessity of each medication
• Clarify any changes or new prescriptions
• Can any medications be stopped? Polypharmacy is a consideration for our aging adults. A pharmacist can help you determine if there are any medications that could or should be discontinued because there are just too many!

This extra step can catch errors that might otherwise slip through the cracks, especially when multiple specialists are involved.

3. Speak Up, Ask Questions, and Advocate

Don’t be afraid to question anything you don’t understand. If a doctor wants to restart a medication that caused problems in the hospital, ask them to review the records. Use phrases like:

• “Can you help me understand why this medication was changed?”
• “Can we double-check the notes from my hospital stay?”

If you’re not comfortable, bring along a family member, friend, or nurse advocate to help you navigate the conversation. Your voice matters—sometimes, it’s the difference between a safe recovery and another hospital visit. For more help on caring for an aging loved one consider our free download “Top FAQs Answered for Caring for an Aging Loved One.”

Final Thoughts: You Are Your Loved One’s Best Advocate

Medication mistakes during transitions are preventable, but it takes awareness, clear communication, and the courage to speak up. If you or someone you care for is facing a change in care setting, don’t go it alone.

At Your Nurse Advocate Consulting, we’re here to help you navigate these critical moments, ask the right questions, and make sure nothing slips through the cracks. If you found this helpful, please share it with someone who might need it. And if you want more resources—like our Emergency to Go Folder checklist or personalized tips for caregivers—drop us a comment or visit our website.

Stay safe, stay empowered, and remember: You are your loved one’s best advocate.

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Need more support during a transition?

Contact us for a free consultation, or check out our caregiver resources and membership options for ongoing guidance from experienced nurse advocates.

Resource Section for Further Help

Additional Resources for Caregivers

1. Local Aging & Disability Resource Centers (ADRCs)

• Your county’s ADRC can help you access services like medication management, home health support, transportation, and caregiver respite. Start here to see what you qualify for and get connected to trusted local providers.

2. Senior Centers & Community Health Clinics

• Many senior centers offer educational workshops on medication safety, chronic disease management, and caregiver support groups. Community health clinics may provide medication reconciliation services or pharmacist consultations.

3. Pharmacist Consultation Services

• Most local pharmacies offer free or low-cost medication reviews. Ask your pharmacist about “medication therapy management” (MTM) to ensure all prescriptions and over-the-counter meds are safe and up to date.

4. National Patient Advocate Foundation

• Patient Advocate Foundation provides case management, financial support, and educational resources for patients and caregivers navigating complex health needs.

5. S.A.F.E. Medication Use Resources

• Institute for Safe Medication Practices (ISMP) offers consumer-friendly tips and printable checklists to help prevent medication errors at home.

6. Family Caregiver Alliance

• Family Caregiver Alliance provides guides, webinars, and support groups for caregivers, including tips on medication management and care transitions.

7. Your Nurse Advocate Consulting Free Tools

• Don’t forget our Emergency to Go Folder checklist, Sibling’s Guide Checklist, and Family Caregiving Meeting Agenda—free resources to help you stay organized and empowered during transitions.

8. Medication Reminder Appshttps://yournurseadvocate.yournurseadvocateconsulting.com/caregiving-faqs.html

• Tools like Medisafe, MyMeds, or your pharmacy’s app can help track doses, set reminders, and share medication lists with family or providers.

9. Medicare’s Medication Therapy Management (MTM) Program

• If your loved one has Medicare Part D, they may qualify for a free MTM review. Ask your pharmacist or plan provider for details.

10. Your Nurse Advocate Consulting.

11. For More Help Caring for an Aging Loved One-Top FAQs Answered

About the Authors

At Your Nurse Advocate Consulting, Pam and Linda’s mission is to empower aging adults and their families to take control of their health, prepare for life’s uncertainties, and secure their peace of mind. We are dedicated to providing compassionate guidance, personalized support, and expert resources to help our clients navigate complex medical needs and organize their personal affairs. 

As independent patient advocates we have a steadfast commitment to clarity, family well-being, and empowerment, we strive to make a meaningful impact by ensuring our clients feel confident, prepared, and cared for every step of the way on their healthcare journey.

Expert Guidance You Can Trust
With over 80 combined years of R.N. experience navigating the complex healthcare system, we stand as trusted guides for seniors and their families. Our expertise ensures they can access the care and resources they need without feeling overwhelmed by red tape or confusion.