Recent article from Critical Care Medicine on the dangers of medication errors in the transition of care

Evaluation of medication errors at the transition of care from an ICU to non-ICU location

Tully AP, Hammond DA, Li C, Jarrell AS, Kruer RM 

Critical Care Medicine. 2019;47(4):543-9.

Transitions of care are a known source of risk. These are points where there can be a failure to communicate important information, failure to adequately transfer or hand over care of a patient between individuals, teams, units or services. This study looked at the specific issue of medication errors for patients transferred from intensive care units (ICUs). The study was a 7-day point prevalence study that encompassed 958 patients who were transferred from an ICU to a non-ICU location in a group of hospitals (34 in the USA and 2 in the Netherlands).

Source: Waitemata District Health Board website

The authors report that 450 patients (45.7%) had a medication error occur during transition of care. Further, among those patients who experienced a medication error, an average of 1.88 errors per patient occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Seventy-five percent of errors reached the patient but did not cause harm. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error. Orders for anti-infective, hematologic agents, and IV fluids, electrolytes, or diuretics at transition of care were associated with an increased odds of error. Factors associated with decreased odds of error included daily patient care rounds in the ICU and orders discontinued and rewritten at the time of transfer from the ICU.

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