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Medication Errors Occur in Nearly Half of ICU Transfers

Patients being transferred out of the intensive care unit encounter medication errors at a rate of 47.5%, although most are not harmful.

Andrea Tully, PharmD, BS

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, according to new data.

While the majority of these errors did, in fact, reach the patients, they tended not to cause significant harm—although the study authors noted that strategies to mitigate these errors should still be implemented. The causes of these errors were multi-factorial and varied.

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 (SD, 1.30; range, 1-9).

“The 3 most common types of errors were [a] continuation of medication with an ICU-only indication (28%), [an] indication with no pharmacotherapy (19%), and pharmacotherapy with no indication (12%),” Tully and colleagues wrote.

The highest odds of an error occurring were associated with anti-infectives (odds ratio [OR], 1.61; 95% CI, 1.16-2.24) hematologic agents (OR, 1.79; 95% CI, 1.20-2.67), and intravenous fluids, electrolytes, or diuretics (OR, 1.69; 95% CI, 1.19-2.41).

In total, 94% of the errors were severity category C—meaning that they reached the patient but did not cause harm—or below. All told, 75% of the errors were in severity category C. Errors varied by size of the institution and ICU, and type of error.

The biggest factors that were related to medication errors occurring were the number of medication orders (OR, 1.06; 95% CI, 1.00-1.11) and the need for renal replacement therapy (OR, 2.90; 95% CI, 1.42-5.95).

“Factors associated with decreased odds of error occurrence included daily patient care rounds in the ICU (OR, 0.14; 95% CI, 0.07-0.29) and orders discontinued and rewritten at the time of transfer from the ICU (OR 0.44; 95% CI, 0.22-0.85),” the study authors noted.

“This study identified risk factors upon which risk mitigation strategies should be focused,” they added. The data was presented at the Society of Critical Care Medicine’s 47th Critical Care Conference in San Antonio, Texas.

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.