Der Verlegungsbericht von der Intensivstation

From the ICU to the ward: Cross-checking of the physician's transfer report by intensive care nurses.

Perren A, Conte P, De Bitonti N, et al.                                                                                                          Intensive Care Med 2008; 34:2054-61

Intensive Care Unit, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland.

OBJECTIVE: To assess whether cross-checking of the physician ICU transfer report by ICU nurses may reduce transfer report errors.
DESIGN: Prospective, observational study with random selection (according to patient registration code) of ICU transfer reports.
SETTING: Eight-bed multidisciplinary intensive care unit of a teaching hospital.
Patients and participants: ICU transfer reports of 123 patients were randomly selected at discharge from the ICU between November 2006 and February 2007.
INTERVENTION: Physician ICU transfer reports were cross-checked by nurses using defined review criteria. Interrater agreement (between nurses and the head of ICU) was assessed by κ-values and was excellent overall (0.9). All intercepted errors (100%) were consequently corrected by the interns.
MEASUREMENTS AND RESULTS: Out of 123 transfer reports, 76 (62%) were affected by at least one error. Among 305 intercepted errors, 247 were prescription errors (26% of all prescriptions), 45 involved proposed procedures and 13 were deficient in updating diagnoses. Most of the errors (248/305, 81%) were classified as simple, 43 (14%) as serious, or 14 (5%) as critical. Thirty-five (28%) transfer reports were considered potentially harmful (i. e., affected by at least one critical/serious error). In a multivariate model, only the number of medications included in the transfer report was associated with the occurrence of at least one critical/serious error.
CONCLUSION: Errors in ICU transfer reports are frequent and may be potentially harmful. ICU nurses may help to effectively and accurately intercept those inaccura-cies and therefore reduce the exportation of errors from the ICU to the ward.