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Nursing issues
Study finds medication errors common after Intensive Care Unit transfer
  1. Paige Hacker Bravo
  1. Medical ICU, Duke University Hospital, Durham, North Carolina, USA
  1. Correspondence to Paige Hacker Bravo, Duke University Hospital, Durham, NC 27710, USA; hackerp99{at}

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Commentary on: Tully AP, Hammond DA, Li C, et al. Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Crit Care Med 2019;47:543–9. Doi: 10.1097/CCM.0000000000003633

Implications for practice and research

  • Nearly half of patients transferred from Intensive Care Unit to non-Intensive Care Unit (ICU) settings experience medication error.1

  • Renal replacement therapy, anti-infective medications, haematological agents, intravenous fluids, electrolytes and diuretics prescribed during ICU stay place patients at highest risk for error.

  • Future research must identify innovative interdisciplinary and technological interventions to decrease medical errors among high-risk transfers.


Medication errors at time of hospital discharge to outpatient settings have been thoroughly studied, showing 60% or greater of patients discharged experience medication errors.2–5 Though information …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.