RESUMEN
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.