Introduction: Recent studies have shown that almost half of ICU to floor transfers resulted in at least one medication related error. To our knowledge, prospective pharmacist review within 24 hours of ICU to floor transfer has not been evaluated as an intervention to decrease the risk of medication related errors. The primary objective of this study was to evaluate the impact of prospective pharmacist review following ICU to floor transfer. Methods: This was a two-phase pilot study conducted at Temple University Hospital. The first phase was a prospective medication profile review within 24h of ICU to floor transfer. Phase two was a retrospective analysis evaluating ICU readmission within 7 days. Patients being transferred between 12/11/2021 and 03/04/2022 were included if they met the following criteria: age > 18 years of age, ICU length of stay > 48 hours, and transferred from an ICU to a medical/surgical ward. Secondary endpoints included: types of errors, medication classes involved, cost avoidance, and ICU readmission within 7 days of transfer. Severity of errors were classified by the Overhage and Lukes scale. Descriptive statistics were used to analyze the data. Results: During the 51-day study period, 107 patients were included. Twenty-three patients had a SOFA score > 6 and most patients were transferred from the medical respiratory ICU (n=36). The total number of medication errors identified was 188. There were no Grade A errors and the most common error severity was Grade C (n=33) and E (n=34). The most common type of error was ‘appropriate therapy’ with ‘No indication’ as the most common type of inappropriate therapy. The total cost avoidance was $35,588 over 51 days and the mean time spent per patient was 30 minutes. One patient was readmitted to the ICU within 7 days. Conclusions: Although most errors were Grade C or E, if not caught early, may have resulted in a more severe error. By providing this clinical service at our institution, we estimate an annual cost avoidance of over $250,000 per year. Given our patient population had a lower severity of illness, this value may be higher in a more severely ill population. This study is hypothesis generating, but could justify a full-time clinical pharmacist with a focus on ICU transitions of care.
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