Medication transcription errors between critical care and general wards

Background

Recent studies have shown that up to 80% of patients discharged from critical care encounter problems with their ongoing medication management. In the absence of a single hospital-wide electronic prescribing and medicines administration (EPMA) system, human factors are introduced during the transcription of medicines between systems, which makes the process more prone to errors.

Objectives

The aims were to establish if all medicines from paper charts were accurately transcribed onto EPMA and clinically appropriate to continue.

Standards

100% of transcriptions are correct and clinically appropriate.

Method

Patients who had been transferred from critical care to a general ward between 20 July and 29 September 2023 were identified through comparison of the daily handovers. On the next working day (Monday to Friday), the critical care pharmacist (a prescriber) checked the patient’s EPMA against their paper critical care drug chart, amended any transcription errors, and de-prescribed medicines which were no longer appropriate.

Results

86 patients were audited. Over one third (n=32) of EPMA transcriptions contained discrepancies. A total of 60 discrepancies were found, which were categorised into three key themes:

• 7% (n=22) medicines not transcribed onto EPMA
• 7% (n=22) medicines no longer required which were not removed from EPMA
• 7% (n=16) incorrect dose, frequency or formulation selection on EPMA

More than one in ten (11.7%; n=7) of all transcription errors occurred because EPMA transcriptions were completed too early to include any medication changes made on the day of transfer. Over one third (36.4%; n=8) of the medicines not transcribed to EPMA were medicines prescribed on separate pages of the paper critical care drug chart to the regular medications. Inappropriate medicines prescribed on EPMA included those prescribed prior to the patient’s critical care admission, such as antibiotic courses which had been completed and antihypertensives which had been held or had doses changed during their critical care admission.

Conclusions

The results and key themes are comparable to those of published studies. There will always be a risk of errors occurring during the transcription process, which will only be significantly reduced by implementing a hospital-wide EPMA system. A limitation is that the audit was conducted during the summer period when doctors are new to the hospital systems and consequently may make more errors. However, it highlights the patient safety risk associated with the transcription process. The Faculty of Intensive Care Medicine recommends that medicines reconciliation should happen at transfer from critical care to the general ward. Therefore, a transcription check by a pharmacist, immediately prior to transfer from critical care to the general ward, would reduce the amount of transcription errors for those patients transferred during pharmacist working hours.

This study did not require ethics approval.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.