Some 73% of medication reconciliation errors happen as patients move between care settings, patient safety organization ECRI said in a Sept. 16 report flagging care transitions as one of healthcare’s most dangerous moments.
The figure comes from an ECRI analysis of 10,000 safety events. The Plymouth Meeting, Pa.-based organization released the findings ahead of World Patient Safety Day, observed Sept. 17.
Care transitions cover any patient movement between settings — home to hospital, ICU to stepdown unit, hospital to skilled nursing facility, or long-term care to the emergency department. Each is a point where medications, diagnoses and care instructions can fall through the cracks.
“Things can fall through the cracks, leading to inefficiencies at best, and patient harm at worst,” Shannon Kooker Davila, MSN, RN, ECRI’s vice president of clinical excellence and patient safety, wrote in the report.
ECRI named inadequate communication and coordination during discharge its top patient safety concern for 2025. Poor handoffs contribute to duplicate or missing medications, delayed diagnoses across facilities and diagnostic errors when records don’t sync between systems.
Part of the problem is structural, ECRI said. Health systems often treat handoffs as a documentation step rather than a clinical task, and few assign a single accountable owner to a patient’s transition.
The organization urged leaders to build structured, system-delivered communication into transitions, improve record interoperability and move patient education beyond printed handouts. It also called for treating patients and caregivers as active advocates in the process.
ECRI made seven previously member-only resources on care transitions public for World Patient Safety Day.
