Hospitalization reliably adds medications. Acute illness demands aggressive management, and each clinical turn — a fever, sleepless night, or drop in blood pressure — often prompts another order. Many of those drugs remain on the discharge list even after the original indication has passed, and clinicians recognize the risks. But real-world constraints limit how much can be addressed before patients leave the hospital.

Handoffs, Documentation Gaps, and Medications

“The times that I see the medication burden increase most significantly during hospitalizations is when there are multiple handoffs between providers,” said Ryan J. Buck, MD, a hospitalist and assistant professor of medicine at Northwestern University Feinberg School of Medicine in Chicago. “Sometimes there isn’t good communication about why a new medicine has already been started or providers might have slightly different ideas or opinions about the best way to treat a certain condition but then don’t necessarily stop the previous treatments that have already been started.”

Manisha B. Grover, MD, a board-certified geriatrician and internist at Cooperman Barnabas Medical Center in Livingston, New Jersey, said medication burden often begins in the emergency department.

“At this stage, medications are initiated rapidly to treat acute conditions, manage symptoms, or prevent complications such as venous thromboembolism,” Grover said. “The burden continues to accumulate gradually throughout the hospital stay and may accelerate with clinical decompensation, complications, or change to a higher level of care.”

Often, what starts as a short-period infusion of a drug continues down the line, Buck said.

“Many times medications…such as proton pump inhibitors for GI [gastrointestinal] issues, supplements, or medications for urinary issues are continued because the exact reason for which they are started is not clear,” Buck said. “This is compounded especially for patients who are hospitalized in a different system where access to the outpatient providers notes is limited or not available.”

Neveen S. El-Farra, MD, vice chair for inpatient medicine and hospitalist services at UCLA Health, recently encountered this issue on a hospital medicine expert panel. “This is often a class of medications that is prescribed, but the need to continue the medication is not indicated,” El-Farra said, referring to proton pump inhibitors. In a 2024 study of ICU patients, 44.7% of those discharged on acid-suppressive therapy lacked a documented indication to continue treatment after hospitalization.

Grover pointed to prophylactic therapies that persist in older patients or those with advanced disease.

“Certain medication classes — most notably statins, aspirin, and proton pump inhibitors used for prophylaxis and high-risk medications such as anticoagulation, insulin, oral hypoglycemics, and antiplatelets — often persist at discharge despite unclear ongoing indications,” Grover said.

Final Hours Before Discharge Favor Continuation

“Sometimes it can be very difficult to determine if it’s my role to stop them when it isn’t related to why I am seeing them in the hospital,” Buck said, “or if they are better served discussing it with their regular doctor — who is going to be better positioned to note if they start doing poorly after stopping it in a way that I am not since I likely won’t see them again once they leave my care.”

He described a recent case in which a patient had been started on steroids for a rheumatologic condition but remained on them long after the intended taper period.

“I was eventually able to track down outpatient notes that indicated that the steroids were only supposed to be temporary while she started another anti-inflammatory medication and then the steroids were to be tapered off — but somehow they were just continued,” Buck said. The outpatient provider didn’t know the patient was still taking them.

Grover said obtaining an accurate medication history remains one of the greatest challenges in hospitalist medicine and is essential to safe prescribing at discharge.

“There is often hesitancy to discontinue a medication a patient has been on, and this is sometimes deferred to the outpatient primary care or sub-specialty physicians since these individuals follow patients in the long-term,” El-Farra said.

Blurred Accountability and the Problems After Discharge

“What I see most often are unintentional continuations or omissions, particularly when temporary inpatient medications are carried forward or chronic therapies are dropped without clear intent,” said Anna Dover, PharmD, BCPS, clinical pharmacist and senior director of editorial content at First Databank. Dover previously served in pharmacy leadership and informatics roles in hospital and health system settings.

“From a pharmacist perspective, these issues almost always trace back to an incomplete or inaccurate home medication list — because downstream decisions are only as reliable as the data they’re built on,” Dover said.

“The handoff most often breaks down when medication intent isn’t clearly structured or consistently visible across care settings,” Dover said. “When that context isn’t accessible to outpatient clinicians, pharmacies, and patients, it leads to inappropriate continuation, delays in therapy, and avoidable readmissions.”

Dover said risk is highest for patients with polypharmacy, recent ICU stays, or multiple transitions of care.

“Anticoagulants, insulin, opioids, sedatives, and cardiovascular medications consistently warrant closer monitoring and decision support after discharge,” Dover said.

Modest Interventions and the Barriers to Scaling Them

“The safeguards that work embed pharmacists into EHR [electronic health record]-enabled, team-based workflows that support accurate home medication capture, structured deprescribing, and clear documentation of medication intent that follows the patient across settings,” Dover said. “Having practiced through the early Joint Commission medication reconciliation era — before modern EHRs — it’s clear to me that check-the-box processes fail unless technology actively supports clinical judgment.”

At UCLA Health, El-Farra described a well-resourced system with continuous EHR prompts and dedicated pharmacists.

“We have an [EHR] which continuously prompts the physician to do medication reconciliation, and we also have outstanding and dedicated pharmacists whose role is to perform medication reconciliation,” El-Farra said. “This sometimes involves calling pharmacies to ensure accuracy of the medication list on admission.”

Grover emphasized clear communication at discharge.

“Effective communication between inpatient and outpatient teams is essential for a safe and seamless transition,” Grover said, noting that written discharge paperwork — the After Visit Summary — should clearly outline which medications were continued, discontinued, paused, modified, or newly prescribed.