​​A safety event involving a discharged patient taking too much of a prescribed medication prompted a facility’s liver transplant and clinical leadership teams to perform a root cause analysis. They identified a significant contributing factor to the event: Each transplant service (e.g., lung, liver, etc.) had a different medication reconciliation process upon discharge. Teams from each transplant service and an interprofessional team (including physicians; nurses; pharmacists; advanced practice nurses; Nursing administration and management; case management; and managers from Regulatory, Quality and Patient Safety) collaborated to establish a standardized process for medication reconciliation upon discharge.​

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