(1370) Pharmacy Impact on Med Errors at Transition From ICU in Previously Mechanically Ventilated Patients

Introduction: According to published literature, around 46% of patients experience at least one medication error upon transition our of the ICU, the most common of which include continuation of an ICU specific medication or untreated chronic conditions. These errors could lead to consequences beyond medication adverse effects, such as increased cost to the patient and the health system and even increasing readmission rates. While this problem is well documented in the literature, guidance on prevention is lacking. This study aimed to compare our current practice to a protocolized pharmacy intervention on the incidence of medication errors.

Methods: This retrospective, single center pre-post cohort included the subgroup of adult patients that were on mechanical ventilation for at least 3 days and transitioned out of the ICU to either another inpatient unit, to an outpatient facility, or to home. Patients were excluded upon transition to hospice or death. The primary endpoint was the number of patients with at least one error, defined as a continuation of a medication that was started for an ICU specific indication or the inappropriate discontinuation of or failure to resume at least one chronic home medication. Secondary end points were length of stay, readmission rates, and inpatient costs.

Results: Patients were screened from July 2022 until March 2024, and 41 patients were included in the subgroup analysis. Baseline characteristics were similar between groups. The pharmacy intervention group had a lower overall incidence of errors at 30% vs. 72% in the control (p = 0.008) with the majority of the difference seen being in continuation of SUP (4% vs. 33% (p=0.0310)) and the failure to resume maintenance medications for chronic conditions (17% vs. 61% (p=0.008)) at transition out of the ICU. There were no differences in secondary endpoints except for cost ($248.67 vs. $30.63).

Conclusions: A protocolized pharmacy intervention significantly reduced the number of medication errors patients experienced during transition out of the ICU. This study adds to the limited literature on the pharmacist’s impact at reducing medication errors and highlights the need for a dedicated transitions of care pharmacy service to promote patient safety and reduce cost in our most vulnerable patient population.