care transitions, clinical nurse specialist, medication complexity, medication reconciliation



  1. Knisely, Mitchell R. MSN, RN-BC, ACNS-BC
  2. Bartlett Ellis, Rebecca J. PhD, RN
  3. Carpenter, Janet S. PhD, RN, FAAN


Purpose: The purpose of this article is to identify medication-related considerations for clinical nurse specialist practice by presenting a case report detailing the complexities of medication management, unresolved medication discrepancies, and reconciliation across care transitions.


Background: Care transitions are a vulnerable time for medication-related problems to occur. Unresolved medication discrepancies can lead to adverse drug events and other poor health outcomes, including hospital readmissions and increased healthcare costs. Reconciling medication discrepancies during care transitions has been identified as a national patient safety goal to prevent medication-related problems. Clinical nurse specialists are uniquely qualified to lead and manage efforts to mitigate these problems during care transitions.


Case Presentation: A 72-year-old male patient diagnosed with oral cancer underwent 8 weeks of chemotherapy and radiation treatments. Throughout these 8 weeks, the patient was seen by 4 providers and admitted to the hospital for neutropenia. As a result, a total of 19 new medications were prescribed and 5 medications were discontinued. Medication reconciliation was completed at each visit and at admission and discharge at the hospital. At discharge, the patient's medication regimen was complex, with 38 separate doses of 17 different medications per 24-hour period. Understanding and organizing the daily medication regimen were a consistent challenge for the patient during his illness.


Discussion: This case highlights the complexities of medication regimens and opportunities to improve medication management and reconciliation across care transitions. This case underscores the need for and importance of quality patient-provider communication, assessing and managing medication regimen complexity, evaluating medications against the American Geriatrics Society Beers Criteria, evaluating potential drug-drug or drug-food interactions, and recognizing at-risk behaviors that may lead to medication discrepancies and errors at care transitions. Potential opportunities where clinical nurse specialists could intervene to promote safe and effective medication management across care transitions are presented.


Conclusion/Implications: Clinical nurse specialists have the unique ability to make key contributions and influence medication management and reconciliation across care transitions to promote medication effectiveness and safety.