Medication safety for intensive care patients transferring to a hospital ward: A Hierarchical Task Analysis

Aims and objectives: To identify the task steps involved in intensive care patients transferring to a hospital ward and their potential for human errors, and to prioritise areas to improve medication safety. Background: Intensive care patients recovering to transfer to a hospital ward experience challenges to care continuity and safety, including medication safety. Medication errors are common on this interface of patient care, contributing to the risk of adverse drug events on the hospital ward and beyond. Human factors are an important consideration in these transfer-related medication errors. Methods: A hierarchical task analysis, based on a goal of safe continuity of medication for intensive care patients on transfer to a hospital ward, was developed from local processes taken from four north of England hospital Trusts with electronic prescribing systems. The task analysis was developed and refined by the research team, incorporating documentary review of policies and procedures, and healthcare professional interviews. Failure modes for the key task steps impacting directly on patient medication safety were identified. Finally, ten intensive care healthcare professionals, individually graded each failure mode (1-5) in terms of the probability, criticality and detectability. Median grades for each parameter were used to determine an overall clinical risk score for each task step. Results: Ten task steps were identified (one conditional), comprising a total of 56 subordinate task steps (two conditional). Conditionality was based on integrated electronic prescribing system resource across the care interface. Thirty-four of the 56 (61%) subordinate task steps were considered by the research team to specifically involve medication continuity or safety aspects. Action omissions (operation, check, information communication) accounted for failure modes in twenty-four of the 34 (71%) task steps. Most task steps (25/34 (74%)) had one or more recovery steps, providing further safety opportunities. The medication review task for reviewing and re-introducing long-term medication had the highest cumulative risk score. The top six clinical risk scores for the failure modes involved task steps with some element of communication around medicines. Conclusions: The safe continuity of medication for intensive care patients on transfer to a hospital ward is complex and prone to human error. Failure mode analysis indicated that medication review on intensive care prior to patient transfer, and communication around medication changes and plans, are particularly important risks that require addressing in any intervention developed to improve medication safety in this patient care transition.