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. Crit Care Med. 2019;47:543-549.

Transitions of care, whether from the hospital to the outpatient setting or within the hospitalitself, represent a vulnerable time for patients. Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse events and errors, including medication errors. This study of 58 intensive care units (ICUs) across 34 United States hospitals and 2 Dutch hospitals sought to assess medication errors among patients transferred from ICUs. Of the 985 patients included in the study, almost half (46%) experienced a medication error during transition out of the ICU. Discontinuing orders and reordering medications at the time of transfer out of the ICU as well as daily patient rounding in the ICU were associated with decreased odds of medication error during transition. A past Annual Perspective discussed challenges associated with handoffs and transitions of care.

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