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Almost Half of ICU Transfers Result in Medication Errors

By Jack H. FarnbauchNovember 19, 2018

According to a new study, almost 50% of patients transferred from the intensive care unit (ICU) to a non-ICU location experience a medication error at the time of transition of care. And while the majority of these errors did not cause significant harm, the sheer number of these errors was staggering. The causes of these errors were multi-factorial and varied and the study stresses that steps should be implemented to mitigate these errors. The study, “Evaluation of Medication Errors at the Transition of Care from an ICU to a Non-ICU Location,” was published in Critical Care Medicine.

Led by Andrea Tully, PharmD, BS, a clinical pharmacy specialist in neurocritical care at Christiana Care Health System in Newark, Delaware, the multicenter, retrospective, observational, 7-day point prevalence study examined 985 adult patients from 58 ICUs that were transferred within the same institution to a non-ICU location. The findings revealed that 45.7% of patients (n = 450) had a medication error—an average of 1.88 errors per patient.

According to the study, the highest odds of an error occurring were associated with anti-infectives, hematologic agents, intravenous fluids, electrolytes, or diuretics. The biggest factors that were related to medication errors occurring were the number of medication orders and the need for renal replacement therapy. “Factors associated with decreased odds of error occurrence included daily patient care rounds in the ICU and discontinuing orders and rewriting them at the time of transfer from the ICU,” the study authors noted.

Read more on this troubling issue

Read the entire STAR Research Presentation.