Pills, Spills and Mix Ups: Tips for Medication Management

I will never forget her confusion, the sudden decline in being able to care for herself or function. Overnight, she became debilitated and aged.  That “she” was my paternal grandmother, a woman who took on a bear by staring it down, ready to fire her gun if it moved. The bear knew she wasn’t kidding. When I rushed her to the hospital, I was shocked to learn that she had a severe electrolyte imbalance caused by three different doctors prescribing diuretics and blood pressure medications. None had checked to see what she was currently taking, none had told her what to stop.

That was in 1982. Fast forward to 2016 and a phone call from a dear friend of mine who had just rushed her mother to the hospital. Her mother had declined overnight and upon exploration, they found she was taking multiple medications that caused an adverse reaction. Medication reconciliation had not occurred from the hospital to the home setting which led to her taking all of her medications – past and present. 

What is Medication Reconciliation?

The New England Health Institute defines medication reconciliation and clinical management of medications as, “[E]xplaining differences between the medicines a patient was taking before admission to the hospital and the medicines prescribed for the patient after hospital discharge.” Today, medication mismanagement is one of the most common causes of preventable hospital readmissions.1

Compiling an accurate list of medications that a patient was taking prior to hospitalization is a challenging task that frequently requires care coordinators to contact family members, primary care physicians and community pharmacists for information. Without an accurate list of medications the patient was taking prior to hospitalization, it is impossible to accurately document all of the regimen changes as a result of the hospitalization. This can leave the patient unclear about which prescriptions he or she should take and potentially lead to discrepancies in the medication regimen and even adverse drug events.

While writing down the correct medications and keeping an accurate list available at all times is important, we know that medication reconciliation is more than a slip of paper. It takes tools to assure that systems of medication administration are as error proof as possible.

Document and Manage Medications with Simple Tools

The truth is that it’s far too easy to make a mistake with medications. If a patient doesn’t follow directions properly, they could end up in the hospital. If they can’t identify their medications, they’re at risk. Caregivers can help keep loved ones and patients healthy and safe by:

  • Keeping an accurate account of medications, dosages and occurrences on hand. My elderly parents carry their medication list with them wherever they go. Keep lists tucked into wallets or handbags where they are easily accessible.
  • Relying on a medication management system. I have moved my parents to a full medication management system. This helps limit the opportunity for medications to be mixed up or forgotten.

Simple tools can have tremendous benefit in managing medications. Studies show that normal care patients using a pill box alone see a 13 percent rise in adherence.2 If just a pill box can do that, imagine what a more robust—yet still simple—system could do. Consider a comprehensive medication management program, such as the Ezy-Dose® Medication Management Tool Kit.

Ezy-Dose groupingThis kit is a bundled system that encourages pill planning, consumption and adherence. Ezy-Dose is the only kit in the industry to combine every tool needed to cover each step of the pill-taking process, plus patient education. And it takes the guesswork out for all who are involved—the patient, family members, loved ones and caregivers.


Medication management is at the core of advanced discharge planning and transitional care.3 Providing easy-to-follow tools will encourage a patient to adhere to the proper medication schedules. Taking pills to maintain or improve quality of life shouldn’t be a burden to patient or caregiver.

What medication adherence strategies have worked for you, your patients or your loved ones?


By Martie L. Moore

  1. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Medication compliance: a healthcare problem. Ann Pharmacother. 1993 Sep;27(9 Suppl):S1-24. Review.
  2. Lee, Jeannie Ket al. Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure, and Low-Density Lipoprotein Cholesterol. JAMA. Dec 6-2006 –Vol 296, No. 21
  3. Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf. Vol 3 (2) June 2007.