Elsevier

Journal of Critical Care

Volume 43, February 2018, Pages 366-369
Journal of Critical Care

Clinical Potpourri
The impact of a daily “medication time out” in the Intensive Care Unit,☆☆

https://doi.org/10.1016/j.jcrc.2017.09.018Get rights and content

Highlights

  • Medication errors are an important source of preventable patient harm.

  • Structured checklist-style interventions may help prevent errors.

  • A daily team-based “time out” intervention is a low-cost method to decrease errors.

  • In this study, a large number of medication changes were prompted by a “time out” intervention.

Abstract

Objective

Medical errors play a large role in preventable harms within our health care system. Medications administered in the ICU can be numerous, complex and subject to daily changes. We describe a method to identify medication errors with the potential to improve patient safety.

Design

A quality improvement intervention featuring a daily medication time out for each patient was performed during rounds.

Setting

A 12-bed Cardiac Surgical ICU at a single academic institution with approximately 180 beds.

Intervention

After each patient encounter, the current medication list for the patient was read aloud from the electronic medical record, and the team would determine if any were erroneous or missing. Medication changes were recorded and graded post-hoc according to perceived significance.

Results

This intervention resulted in 285 medication changes in 347 patient encounters. 179 of the 347 encounters (51.6%) resulted in at least one change. Of the changes observed, 40.4% were categorized as trivial, 50.5% as minor and 9.1% were considered to have significant potential impact on patient care. The average time spent per patient for this intervention was 1.24 (SD 0.65) minutes.

Conclusions

A daily medication time out should be considered as an additional mechanism for patient safety in the ICU.

Introduction

Since the Institute of Medicine's seminal report in 1999, medical errors have garnered significant attention [1], and more recently medical errors have been cited as the third leading cause of death in the US [2]. While the exact figures have been called into question [3], it is undeniable that medication errors play an important role in preventable harms within our health care system. Many different mechanisms contribute to errors, but cognitive omission or oversight may be particularly amenable to a “time out” approach.

Structured checklists have become standard practice in many settings, most famously in the aviation industry, but also in medicine [4]. A time out prior to surgical procedures is now required in most settings [5], and indeed surgical safety checklists have demonstrated improved mortality [6].

The Intensive Care Unit (ICU) is a complex care environment requiring particularly careful attention. Patients often have multiple concomitant life-threatening issues, and teams are responsible for the management of many critically ill patients simultaneously. Additionally, academic institutions may have large cadres of rotating service providers from different specialties, with various levels of experience. This creates an environment particularly susceptible to medication errors, and ideal for methods to create standardization and decrease errors. Although recommended by various sources [7], daily medication review of each patient every day is currently not standard practice in all hospitals, and its effect has not been quantified in the ICU setting.

We hypothesized that a standardized, team-based approach to checking medications each day (“medication time out”) during morning rounds would detect medication errors and thereby improve patient safety.

Section snippets

Methods

A quality improvement intervention was created to perform daily medication time outs on each patient during morning rounds. This occurred between November 2015 and February 2016, in the 12 bed Cardiac Surgical Intensive Care Unit of an academic tertiary care center. After review, additional data were collected Feb-March 2017, including the time involved to perform the time out intervention. The ICU team consists of an attending physician intensivist, critical care fellow, residents, medical

Results

Overall, the daily medication time out resulted in 285 medication changes in 347 patient encounters (0.82 changes per encounter). One hundred seventy-nine of the 347 encounters (51.6%) resulted in at least one change. Of the encounters with at least one change, there was an average of 1.6 changes per patient. These data were similar between the initial observation period (11/15–2/16 showed 121 changes in 237 encounters, 51.1%) and the second observation period (2/17–3/17 showed 58 changes in

Discussion

Our study found that a standardized daily medication time out during rounds in the ICU resulted in a large number of medication changes. The time out occurred after the conclusion of rounds for each patient, so it can be assumed that these changes would not have occurred without this intervention. Several changes were thought to impact patient safety and the intervention therefore likely prevented potential harm. Even though not specifically recorded, changes occasionally occurred in subsequent

Conclusions

A simple intervention of reading aloud a patient's active medication orders at the end of rounds resulted in a significant number of medication changes, many with potential to impact patient safety. This method is inexpensive, brief, immediately available to all teams caring for critically ill patients, and requires no additional personnel or equipment. Routine implementation of a daily medication time out should be considered as an additional mechanism for improving patient care in the ICU.

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No financial support was provided for this manuscript.

☆☆

None of the authors have any competing interests in this manuscript.

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