Medication Safety During Transitions of Care: The Importance of Checklists in Preventing Patient Harm


  • Laressa Bethishou, PharmD, APh, BCPS Chapman University School of Pharmacy
  • Olivia Lounsbury Patient Safety Movement Foundation
  • Donna Prosser, DNP, RN Patient Safety Movement Foundation


There is a need to optimize patient safety as patients navigate through the healthcare system. With each transition of care, patients are vulnerable to changes that may cause adverse effects, including changes in their healthcare team, health status, and medications. The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as “the movement of a patient from one setting of care to another.” While the concept itself may seem simple, this definition fails to capture the many potential handoff complications which classify these transitions as high risk for patients. With 67% of patients facing unintended medication discrepancies in the hospital and more than 40% of medication reconciliation errors resulting from miscommunications in handoffs, medication safety has become a leading priority for patients and caregivers. The World Health Organization articulated the need to improve communication specifically during points of transition. Differences in communication styles, distracting environments, and the lack of standardization are the primary factors contributing to the 80% of medical errors resulting from transitional miscommunication.

Author Biographies

Laressa Bethishou, PharmD, APh, BCPS, Chapman University School of Pharmacy

Laressa Bethishou ( is assistant professor and director of co-curriculum, Pharmacy Practice, at Chapman University School of Pharmacy in Irvina, California. Her research interests include evaluating the impact of pharmacist interventions on high-risk patient populations, such as heart failure patients, asthma and COPD exacerbations, and pneumonia admissions.

Olivia Lounsbury , Patient Safety Movement Foundation

Olivia Lounsbury is a clinical intern at the Patient Safety Movement Foundation and a junior at Chapman University in Orange, California, where she is pursuing a double major in Health Science and Policy and Behavioral Studies.

Donna Prosser, DNP, RN, Patient Safety Movement Foundation

Donna Prosser is chief clinical officer at the Patient Safety Movement Foundation. She is a Fellow in the American College of Healthcare Executives and is board certified as a Nurse Executive by the American Nurses Credentialing Center and as a Patient Advocate by the Patient Advocate Certification Board.



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How to Cite

Bethishou, L., Lounsbury , O. ., & Prosser, D. (2020). Medication Safety During Transitions of Care: The Importance of Checklists in Preventing Patient Harm. Patient Safety, 2(2), 48–55. Retrieved from



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