• Peter Pronovost, Brad Weast, Mandalyn Schwarz, Rhonda M Wyskiel, Donna Prow, Shelley N Milanovich, Sean Berenholtz, Todd Dorman, and Pamela Lipsett.
• Department of Anesthesiology and Critical Care Medicine Surgery and Health Policy and Management, The Johns Hopkins University, Baltimore, MD 21231, USA. ppronovo@jhmi.edu
• J Crit Care. 2003 Dec 1; 18 (4): 201-5.

AbstractPreventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

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