Background Medication discrepancies between actual and documented therapy often arise at patient transfer between wards. Intensive care unit(ICU) patients are particularly prone because of polymedication, frequent therapy changes and impaired consciousness, with also an increased risk for drug related problems (DRPs).

Purpose To determine the type and frequency of medication discrepancies and DRPs on admission, during ICU stay and on transfer to the ward, and the clinical pharmacist’s role in prevention.

Material and methods This was a prospective before and after study on adult patients after informed consent, in two ICU units (general and cardiology; 12 beds) in a tertiary care university hospital. During an 8 week observation period (October 2015 to January 2016) a clinical pharmacist conducted a standardised drug reconciliation on ICU admission, twice weekly drug review and review on patient transfer. These data were compared with physicians’ notes and prescriptions. Discrepancies and potential DRPs were classified using a standardised flow chart. During a subsequent 16 week intervention period (January–May 2016), the pharmacist additionally entered compiled drug histories in the patient files, participated in clinical rounds and proactively provided feedback.

Results 111 patients were included (observation 50; intervention 61). On ICU admission, we found a significant difference in the number of drugs found after medication reconciliation by the physician compared with the pharmacist (observation 5.5 vs 8.5/patient; intervention 6 vs 8/patient; both p<0.0001). Furthermore, during the intervention period we saw a reduction in DRPs during ICU stay (5 vs 3/patient; p=0.06) and a reduction in median number of discrepancies (1 vs 0/patient; p=0.0067) and DRPs (3 vs 1/patient; p=0.0009) at patient transfer. The proportion of transfer discrepancies due to incomplete drug reconciliation showed a similar reduction (17.9% vs 5.1%; p=0.0061). Most frequent DRPs at patient transfer were incomplete reconciliation (26.2%), missing therapy duration (22.7%) and inadequate administration route (20.6%). Main transfer discrepancies were omission (59%), frequency (12%), addition (11%) and dose (11%). During the intervention period, the pharmacist proposed a total of 683 interventions with an 92.7% acceptance rate.

Conclusion A clinical pharmacist, integrated in a multidisciplinary ICU team, can make a significant contribution to medication safety by preventing drug discrepancies on admission, by identification of DRPs during ICU stay and by reducing discrepancies on transfer to a normal ward.

No conflict of interest