October 6, 2026
Advocating for Safer Medication Orders and Reconciliation at Transitions of Care in Assisted Living: A Prescriber's Role
By Burton Korer, DNP, MSN, RN-BC, PhD Candidate
Medication discrepancies affect an estimated 86.2% of assisted living (AL) residents transitioning from a hospital stay, and medication errors occur in 13to 31% of all care transitions, with a quarter causing resident harm.1,2 Under most state AL regulations, the licensed community—not the prescriber or pharmacy—is accountable for medication management, including the accuracy of the medication administration record and the reconciliation processes that support it. However, specifics vary by state.3
That accountability is both functional and regulatory; only the community can add, change, or delete electronic Medication Administration Record (eMAR) entries, and only the community can see the live record. A common misconception is that the pharmacy works within the electronic medical record (EHR), but there is limited data exchange between the EHR and the pharmacy dispensing system. Neither the prescriber nor the pharmacy has the capability of overseeing day-to-day nursing tasks, yet nearly every reconciliation failure traces back to an order, its clarity, timing, or completeness. Prescribers can leverage a unique role. They can materially reduce discrepancy risk by how they write orders, communicate changes, and engage with facility staff and pharmacists. What follows is a discussion of the levers within a prescriber's control.
Write orders that cannot be misread
The highest-yield habit is to explicitly discontinue or modify administration instructions on any order that changes an existing regimen.4 Adding a new antihypertensive without an accompanying “discontinue [prior drug, dose, frequency]” leaves both medications active in systems that do not autoreconcile. Duplicate therapy remains one of the most common preventable transition errors.5 Prescribers should avoid using an informal medication list — verbal, texted, or handwritten — in place of a formal prescription. Lists lack the dose, route, frequency, indication, and signature that make an order actionable and legally sufficient in most states, and they invite transcription errors at every hand-off. Discharge orders should state anticipated titration plans, an end date for time-limited therapy, and the rationale for any change.6
Own the three highest-risk transitions
- Admission: Communities compile a “best possible medication history” from the resident, family, prior pharmacy, and hospital records — a process that can take 46 minutes per resident.7 Prescribers shorten and reduce the medication safety risk in this process by ensuring that transfer documentation, including physician orders for life-sustaining treatment and advance-care-planning forms, is complete and reaches the community at or before resident arrival.6
- Return from hospital or skilled nursing facility: This is the highest-risk transition, wherein 86.2% of records show at least one discrepancy; omitted analgesics and anticoagulants are common, harmful errors.1,5 Discharge documentation should explicitly state what was started, stopped, or changed, and why. When facility staff or a consulting pharmacist raises a question (“was this intentionally stopped?”), a prompt response matters clinically: physicians who respond quickly to pharmacist-identified discrepancies measurably reduce discrepancy-related adverse drug events, with one study reporting odds reduced to 0.11.5 These queries deserve same-day attention, not routine
- Post-visit changes: Any medication change made during a routine visit warrants a written or electronic order sent to the community and pharmacy the same day. Verbal reports relayed by the resident or family do not suffice.8
Advocate against telephonic workarounds
A persistent risk in AL is community staff calling in prescriptions to the pharmacy on a prescriber's behalf. This practice compounds transcription risk, often exceeds the unlicensed staff's scope of authority, and blurs accountability. Prescribers are well-positioned to close this gap by using electronic order entry wherever available, direct communication with the pharmacy for urgent orders instead of relaying them through staff, and asking for read-back verification when a verbal order cannot be avoided.9 Advocating for an AL policy that prohibits unauthorized telephonic prescribing and models direct prescriber-to-pharmacy communication removes an avoidable point of failure.
Coordinate deliberately with hospice prescribing and dispensing
Hospice-enrolled residents pose a distinct telephonic risk. Hospice teams frequently call new or changed orders directly to the hospice's contracted dispensing pharmacy, which is often not the community's primary pharmacy connected to the EHR. Physicians should know that the hospice pharmacy may not be connected to the EHR and thus it cannot directly transmit new prescription information to the community EHR for hospice and other medications obtained from retail or mail-order pharmacies.
In this example, the hospice pharmacy fills the order, but a separate communication is still required, usually relayed by community staff via phone or fax, to get it into the AL’s EHR. Two verbal hand-offs of the same order to two different pharmacies create two independent opportunities for the dose, frequency, or drug name to become disparate, leading to a medication error.
Facility staff should understand that the AL’s primary dispensing pharmacy does not dispense hospice medication, and has no dispensing record against which to check the transcribed order. Where feasible, prescribers should send hospice orders in writing to both the AL and hospice pharmacies simultaneously, designate one document as authoritative, and periodically confirm the eMAR entry against the dispensing record.
Engage the system, not just the order
Pharmacist-led reconciliation during hospital-to-AL and skilled nursing transitions is among the most effective single interventions, reducing both discrepancy-related adverse events and readmissions.5,10 Prescribers can advocate for collaborative practice agreements with consulting pharmacists, timely response protocols for discrepancy queries, and standardized transfer forms that capture medication, dose/route, frequency, last dose given, and indication.7 Medication reconciliation operates optimally when it is shared clinical work rather than a clerical afterthought.
Conclusion
AL prescribers are not the party held accountable by regulations for medication management, but they originate drug orders. Explicit, complete, and promptly communicated orders, paired with prompt responses to pharmacist queries and advocacy against unsafe workarounds, such as unauthorized telephonic prescribing and unreconciled hospice dual-pharmacy orders, are levers that prescribers use to improve medication safety. With a quarter of transition-related medication errors causing resident harm, these are not administrative preferences; they are patient safety interventions available to prescribers.1,2
References
1. Fitzgibbon M, et al. Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living. J Gerontol Nurs. 2013. https://doi.org/10.3928/00989134-20130930-02
2. Kandiah J, et al. Contextual factors influencing medicines-related interventions to support safe transitions for care home residents post-hospital discharge: a systematic review and meta-ethnographic synthesis. Inter J Clin Pharm. 2022. https://doi.org/10.1007/s11096-022-01507-3
3. Sikma SK, et al. Medication management roles in assisted living. J Gerontol Nurs. 2014. https://doi.org/10.3928/00989134-20140211-02
4. Johnson M, et al. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc 2015. https://doi.org/10.1331/JAPHA.2015.15509
5. Boockvar KS, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother. 2006. https://doi.org/10.1016/J.AMJOPHARM.2006.09.003
6. Davidson GH, et al. Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities. Am J Surg. 2017. https://doi.org/10.1016/J.AMJSURG.2017.04.002
7. Pevnick JM, et al. The problem with medication reconciliation. BMJ Qual Safe. 2016. https://doi.org/10.1136/BMJQS-2015-004734
8. Koff MD, et al. Medication reconciliation at transition of care in a geriatric primary care setting: a pilot program. Sr Care Pharm. 2025. https://doi.org/10.4140/tcp.n.2025.217
9. Elliott RA, et al. Electronic prescribing and medication management at a residential aged care facility: uptake by general practitioners and qualitative evaluation of the benefits and barriers. App Clin Inform. 2016. https://doi.org/10.4338/ACI-2015-08-RA-0098
10. Phillips M, et al. 30-dy readmission reduction in a skilled facility population through pharmacist-driven medication reconciliation. J Healthcare Qual. 2022. https://doi.org/10.1097/jhq.0000000000000313
Burton Korer is a registered nurse and owner-operator of a long-term care pharmacy in Arizona. He is also employed as a board-certified case manager in an acute-care hospital system, where he supports transitions of care between health-care settings.