Medication reconciliation (often called “med rec”) can be pretty boring, but med rec done right can be lifesaving.  A 89 year old male was hospitalized with a GI bleed and significant anemia.  This patient’s baseline hemoglobin was already in the 10-11 range prior to the GI bleed secondary to chronic kidney disease.  Upon discharge from the hospital, anemia was improving, but hemoglobin was still only around 8.  It was obvious from reading the progress notes from that hospital stay, that his aspirin was not going to be continued due to GI bleed risk.  On the discharge medication reconciliation form, the aspirin was checked to be discontinued.  What the staff didn’t realize was that this form had changed and when I checked the active medication list, this patient was still receiving the aspirin.  This had slipped by two healthcare professionals because their med rec form had changed (i.e. they weren’ t used to identifying the medication orders on that new form).  This patient did end up receiving the aspirin for a couple weeks, fortunately without issue.  It is very easy to get into “auto-pilot” mode, but we must think critically at all times!

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