Background and importance Patients are vulnerable to medication error(s) at discharge from the paediatric intensive care unit (PICU). Clinical outcomes may be compromised if medicines are inappropriately continued, omitted or prescribed incorrectly. There is an additional risk at Evelina London Children’s Hospital (ELCH) as a different prescribing system is used in ward areas (MedChart) and the PICU (eVision). Currently, critical care doctors complete the discharge summary and verbally handover patients to the ward team(s). Ward doctors are responsible for transcribing medicines from eVision to MedChart and ward pharmacists are responsible for completing the medication review. Audits have shown that prospective critical care pharmacist (CCP) step-down checks can lead to mitigation of medicine related transfer of care errors.

Aim and objectives Our aim was to assess the current PICU discharge process and review the risk of medication related errors. The objectives were to measure the time taken for medicines to be transcribed from eVision to MedChart; to measure the time taken to complete a discharge medication review; to identify the percentage of transcription errors that occur and classify errors to assess potential risk; and to identify ways to mitigate the risk associated with the current process

Material and methods A data collection tool was designed using Microsoft Excel. Prospective data collection took place from 20 July to 7 August 2020. Patients were identified using the ‘discharge’ tool on eVision. 29 PICU discharge transcription charts were reviewed; the number of charts with errors was identified and classified by a PICU pharmacist.

Results Average time taken for a doctor to transcribe medicines from eVision to MedChart was 1 hour 50 min. Average time taken for a pharmacist to complete the transcription check on MedChart was 10 hours 54 min. 35% of transcription charts displayed one or more errors. 40% of the identified errors were classified as simple (unlikely to result in harm), and 60% were classified as serious (potential to cause reversible harm).

Conclusion and relevance To mitigate the risk associated with the current process, it is proposed that PICU doctors complete the transcription of medicines from eVision to MedChart prior to the patient leaving the PICU, and paediatric CCPs perform discharge medication reviews. By involving the PICU team in the medication discharge process, we aim to improve the quality and safety of step-down prescribing.

Conflict of interest No conflict of interest