I r o p a a s t h t r d c t m f m l PATIENTS ARE most at risk during the transition of care (hand-off) across settings, services, providers, or levels of care. The development, reconciliation, and communication of an accurate medication list throughout the continuum of care are essential in the reduction of transition-related adverse drug events. Goal #8 of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 2006 National Patient Safety Goals (NPSGs) is to accurately and completely reconcile medications across the continuum of care. NPSG #8 requires organizations to implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. Dr Richard J. Croteau, Executive Director for Strategic Initiatives at the JCAHO, states that medication reconciliation is important because it addresses the most frequently occurring type of medical error (medication errors), the most frequently cited category of root causes for serious adverse events (ineffective communication), and the most vulnerable parts of a process (the handoffs in the transition of care).