Prevent Med Errors at ICU Transitions of Care

Almost half of patients experience a med error when transferring out of the ICU.

Use these strategies to help reduce mishaps.

Ensure patient-specific meds are transferred with the patient...to prevent late or missed doses.

For example, look for prepped IV meds in the fridge...or a patient’s home med in a patient-specific bin or drawer.

Be aware, about 75% of home meds are held during critical illness. Review a patient’s home med list at transfer...and ask the prescriber if any of the held meds should be restarted.

Check that any ICU-only meds are taken off a patient’s med list.

These meds...such as norepinephrine (Levophed) or another pressor or cisatracurium (Nimbex) or another paralyzing agent...are usually titrated to “off,” but a discontinue order isn’t written.

If you see that a med was ordered as part of an ICU protocol, use this as a cue to ask if it should be stopped at transfer.

For example, pantoprazole (Protonix) or another acid reducer may have been started for stress ulcer prophylaxis in a severely ill ICU patient. But this isn’t indicated for floor patients.

Plus haloperidol, quetiapine (Seroquel), and other antipsychotics for ICU delirium are often continued unnecessarily after transfer out of ICU, sometimes even after discharge.

Work with your pharmacist to get IV meds switched to PO.

And ensure med administration routes get changed from per tube to oral after a patient’s feeding tube is pulled.

Keep an eye out for dose adjustments...due to changes such as improving renal function. Place discontinued doses in the return bin on your unit...so they aren’t given by mistake.

See our Transitions of Care Checklist for more tips.

Key References
  • Crit Care Med 2019;47(4):543-9
  • Ann Intensive Care 2018;8(1):19
  • Ann Pharmacother 2019;53(6):596-602
Nurse’s Letter. Jun 2019, No. 350625


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