Medication Errors Common in ICU Transfers

A new report by Christiana Care Health System showed that medication errors occurred in 47 percent of ICU Transfers. The study which followed 985 patients at almost 60 different ICUs across the East Coast who were transferred from the ICU to a non-ICU area in the same hospital or medical unit.  According to the study, an average of 1.88 errors occurred per patient transferred out of the ICU, a startlingly high number.

The report, authored by Andrea Tully and detailed in, found that the most common errors related to anti-infectives, hematologic agents, and intravenous fluids, electrolytes or diuretics. The patients with the highest risk of a medication error were patients taking the most medications and patients in need of renal replacement therapy. While 75 percent of these medication errors were deemed “Category C” which meant no actual harm or minimal harm caused to the patient, a full 25 percent caused harm to the patient. According to patient care advocates, these numbers are unacceptable.

The study also identified hospitals with lower medication errors occurring in ICU transfers. These hospitals typically had daily patient care rounds in the ICU and required all prescriptions and medical orders to be rewritten at the time the patient is transferred out of the ICU.   Further, patients at hospitals with electronic records also showed a reduced risk of medication errors.

While most medication errors do not harm patients during an ICU transfer, the disturbingly high number of errors should be a cause for concern, according to the study’s author.  For the 25 percent of patients who are harmed by these errors, extended time in the hospital to recover and, in some circumstances, even more long-term harm could be entirely prevented. For these reasons, “This study identified risk factors upon which risk mitigation strategies should be focused,” the study’s author told a medical conference.

Contact the Law Offices of Thomas L. Gallivan, PLLC if you have any questions regarding medication errors or medical malpractice.

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