A practical tool to reduce medication errors during patient transfer from an intensive care unit

Peter Pronovost, Deborah Baugher Hobson, Karen Earsing, Elizabeth S. Lins, Michael L. Rinke, Katherine Emery, Sean M. Berenholtz, Pamela A. Lipsett, Todd Dorman

Research output: Contribution to journalArticle

14 Scopus citations


• Objective: To decrease medication errors that occur during the transfer of patients from a surgical intensive care unit (ICU) by institution of a computerized medication reconciliation tool. • Design: Prospective cohort study. Setting and participants: Patients admitted to a 16-bed surgical ICU in an academic medical center. • Measurement: Proportion of medical records with at least 1 error identified. Secondary outcomes included compliance with the tool and number of medication orders changed. • Results: Over the 1-year study period, 1455 medication reconciliation forms were completed. 636 medication orders were changed as a result of the medication form, and 299 (21%) individual patients required at least 1 change. An average of 12.2 orders were changed per week, affecting an average of 6 patients per week. There was a high rate of compliance with the form. • Conclusion: The implementation of a simple, inexpensive tool is associated with a decrease in medication errors that reach patients during transfer from a surgical ICU.

Original languageEnglish (US)
Pages (from-to)26-33
Number of pages8
JournalJournal of Clinical Outcomes Management
Issue number1
Publication statusPublished - Jan 1 2004
Externally publishedYes


ASJC Scopus subject areas

  • Health Policy

Cite this

Pronovost, P., Hobson, D. B., Earsing, K., Lins, E. S., Rinke, M. L., Emery, K., ... Dorman, T. (2004). A practical tool to reduce medication errors during patient transfer from an intensive care unit. Journal of Clinical Outcomes Management, 11(1), 26-33.