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Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location

Tully, Andrea P. PharmD1; Hammond, Drayton A. PharmD, MBA2; Li, Chenghui PhD3; Jarrell, Andrew S. PharmD4; Kruer, Rachel M. PharmD4

doi: 10.1097/CCM.0000000000003633
Clinical Investigations

Objectives: To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care.

Design: This was a multicenter, retrospective, 7-day point prevalence study.

Setting: Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands.

Patients: Nine-hundred eighty-five patients transferred from an ICU to non-ICU location.

Interventions: None.

Measurements and Main Results: Of 985 patients transferred, 450 (45.7%) had a medication error occur during transition of care. Among patients with a medication error, an average of 1.88 errors per patient (sd, 1.30; range, 1–9) 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. The occurrence of errors varied by type and size of institution and ICU. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error (odds ratio, 2.93; 95% CI, 1.42–6.05; odds ratio 1.08, 95% CI, 1.02–1.14, respectively). Orders for anti-infective (odds ratio, 1.66; 95% CI, 1.19–2.32), hematologic agents (1.75; 95% CI, 1.17–2.62), and IV fluids, electrolytes, or diuretics (odds ratio, 1.73; 95% CI, 1.21–2.48) 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 (odds ratio, 0.15; 95% CI, 0.07–0.34) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36; 95% CI, 0.17–0.73).

Conclusions: Nearly half of patients experienced medication errors at the time of transition of care from an ICU to non-ICU location. Most errors reached the patient but did not cause harm. This study identified risk factors upon which risk mitigation strategies should be focused.

1Department of Pharmacy, Christiana Care Health System, Newark, DE.

2Department of Pharmacy, Rush University Medical Center, Chicago, IL.

3Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR.

4Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD.

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Dr. Jarrell received funding from Intensive Care On-line Network (presenting education webinars) and Living Legacy Foundation (grant to conduct a pharmacokinetic study in solid organ transplant patients). The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed at the Blount Memorial Hospital; Cape Coral Hospital; Chambersburg Hospital; Christiana Care Health System; ErasmusMC University Medical Center Rotterdam, Netherlands; Eskenazi Health; Florida Hospital Orlando; Florida Hospital East Orlando; Gulf Coast Medical Center; Health Park Medical Center; Johns Hopkins Bayview Medical Center; Loma Linda University Children’s Hospital; Loma Linda University Medical Center; Lee Memorial Hospital; Mary Washington Hospital; Mayo Clinic Hospital—Rochester; Memorial Hermann-Texas Medical Center; Mercy Health St. Charles Hospital; Sharp Grossmont Hospital; Southwest General Health Center; St. Mary Medical Center; Stanford Health Care; The Hospital of Central Connecticut; The Johns Hopkins Hospital; University Hospitals Cleveland Medical Center; University Hospitals Geauga Medical Center; University Hospitals Parma Medical Center; University Hospitals St. John Medical Center; University Medical Center Groningen, Netherlands; University of Alabama at Birmingham Hospital; University of Arkansas for Medical Sciences; University of California San Diego Health; University of Kentucky HealthCare; University of Virginia Health System; Vanderbilt University Medical Center; and Wake Forest Baptist Medical Center.

Address requests for reprints to: Rachel M. Kruer, PharmD, Department of Pharmacy, The Johns Hopkins Hospital, 600 North Wolfe Street—Carnegie Bldg Room 180, Baltimore, MD 21287. E-mail:;

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