Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence

Drug Safety

Volumn 36, Issue 11, 2013, Pages 1045-1067

  Keers, Richard N ^a   Williams, Steven D ^a,b   Cooke, Jonathan ^a,c   Ashcroft, Darren M ^a  

^a UNIVERSITY OF MANCHESTER   (United Kingdom)

^b MANCHESTER UNIVERSITY NHS FOUNDATION TRUST   (United Kingdom)

^c IMPERIAL COLLEGE LONDON   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ACCIDENT; CULTURAL ANTHROPOLOGY; HEALTH STATUS; HOSPITAL; HUMAN; INTERPERSONAL COMMUNICATION; KNOWLEDGE; MEDICAL DOCUMENTATION; MEDICATION ERROR; PATIENT ATTITUDE; PERSONALITY; PHARMACIST; PHARMACY; PHARMACY STUDENT; PRESCRIPTION; PRIORITY JOURNAL; REVIEW; SYSTEMATIC REVIEW; WORK ENVIRONMENT;

DATA COLLECTION; DATABASES, FACTUAL; DRUG PRESCRIPTIONS; HOSPITALS, TEACHING; HUMANS; MEDICATION ERRORS; MODELS, THEORETICAL; PATIENT CARE TEAM; PHARMACEUTICAL PREPARATIONS; QUALITY ASSURANCE, HEALTH CARE; WORKLOAD;

EID: 84887165647     PISSN: 01145916     EISSN: 11791942     Source Type: Journal    
DOI: 10.1007/s40264-013-0090-2     Document Type: Review

References (111)

1. Leape LL. Errors in medicine. Clin Chim Acta. 2009;404(1):2-5.
2. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-23.
3. Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy. Epub 2013 May 17. doi: 10.1002/phar.1287.
4. Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J Qual Patient Saf. 2012;38(3):120-6.
5. Bates DW, Boyle DL, Vander Vliet MB, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205.
6. Buckley MS, Erstad BL, Kopp BJ, et al. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med. 2007;8(2):145-52.
7. Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006;34(2):415-25.
8. Keers RN, Williams SD, Cooke J, et al. Prevalence and nature of medication administration errors in healthcare settings: a systematic review of direct observational evidence. Ann Pharmacother. 2013;47(2):237-56.
9. McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89.
10. Kale A, Keohane CA, Maviglia S, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8.
11. Pepper GA. Errors in drug administration by nurses. Am J Health Syst Pharm. 1995;52(4):390-5.
12. Armitage G. Human error theory: relevance to nurse management. J Nurs Manag. 2009;17(2):193-202.
13. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
14. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
15. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7.
16. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). NCC MERP taxonomy of medication errors. 1998. Available from URL: http://www.nccmerp.org/pdf/taxo2001-07-31.pdf. Accessed: 2013 July 2.
17. National Reporting and Learning Service. RLS Help System. Available from URL: https://www.eforms.nrls.nhs.uk/staffreport/help/ALL/eForm-Help.htm. Accessed 2013 July 2.
18. Reason J. Human error. Cambridge: Cambridge University Press; 1990.
19. Mayo AM, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual 2004; 19(3):209-17.
20. Ulanimo VM, O'Leary-Kelley C, Connolly PM. Nurses' perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual. 2007; 22(1):28-33.
21. Tully MP, Ashcroft DM, Dornan T, et al. The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(10):819-36.
22. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59(5):436-46.
23. Meyer-Massetti C, Cheng CM, Schwappach DLB, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227-40.
24. Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm. 1990;47(3):555-71.
25. Barker KN. Data collection techniques: observation. Am J Hosp Pharm. 1980;37(9):1235-43.
26. Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm. 2001;58(1):54-9.
27. Brady AM, Malone AM, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97.
28. Armitage G, Knapman H. Adverse events in drug administration: a literature review. J Nurs Manag. 2003;11(2):130-40.
29. Fry MM, Dacey C. Factors contributing to incidents in medicine administration. Part 1. Br J Nurs. 2007;16(9):556-8.
30. McBride-Henry K, Foureur M. Medication administration errors: understanding the issues. Aust J Adv Nurs. 2006; 23(3):33-41.
31. Carlton G, Blegen MA. Medication-related errors: a literature review of incidence and antecedents. Annu Rev Nurs Res. 2006;24:19-38.
32. O'Shea E. Factors contributing to medication errors: a literature review. J Clin Nurs. 1999;8(5):496-504.
33. Gonzales K. Medication administration errors and the pediatric population: a systematic search of the literature. J Pediatr Nurs. 2010;25(6):555-65.
34. Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 2003;326(7391):684.
35. Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate Publishing Limited; 1997.
36. Reason J. Understanding adverse events: human factors. Qual Health Care. 1995;4(2):80-9.
37. Taxis K, Dean B, Barber N. Hospital drug distribution systems in the UK and Germany - a study of medication errors. Pharm World Sci. 1999;21(1):25-31.
38. Dean BS, Allan EL, Barber ND, et al. Comparison of medication errors in an American and a British hospital. Am J Health Syst Pharm. 1995;52(22):2543-9.
39. Wirtz V, Taxis K, Barber ND. An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm World Sci. 2003;25(3):104-11.
40. Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care. 2003;12(5):343-7.
41. Taxis K, Barber N. Causes of intravenous medication errors - observation of nurses in a German hospital. J Public Health. 2004;12(2):132-8.
42. Treiber LA, Jones JH. Devastatingly human: an analysis of registered nurses' medication error accounts. Qual Health Res. 2010;20(10):1327-42.
43. Treiber LA, Jones JH. Medication errors, routines, and differences between perioperative and non-perioperative nurses. AORN J. 2012;96(3):285-94.
44. Taxis K, Barber N. Incidence and severity of intravenous drug errors in a German hospital. Eur J Clin Pharmacol. 2004;59(11):815-7.
45. Jones JH, Treiber L. When the 5 rights go wrong: medication errors from the nursing perspective. J Nurs Care Qual. 2010;25(3):240-7.
46. Dean B, Barber N. The effects of a patients' own drugs scheme on the incidence and severity of medication administration errors. Int J Pharm Prac. 2000;8(3):209-16.
47. Ho CYW, Dean BS, Barber ND. When do medication administration errors happen to hospital inpatients? Int J Pharm Prac. 1997;5(2):91-6.
48. Cavell GF, Hughes DK. Does computerized prescribing improve the accuracy of drug administration? Pharm J. 1997;259(6968):782-4.
49. Bruce J, Wong I. Parenteral drug administration errors by nursing staff on an acute medical admissions ward during day duty. Drug Saf. 2001;24(11):855-62.
50. Hartley GM, Dhillon S. Observational study of the prescribing and administration of intravenous drugs in a general hospital. Int J Pharm Prac. 1998;6(1):38-45.
51. Hand K, Barber N. Nurses' attitudes and beliefs about medication errors in a UK hospital. Int J Pharm Prac. 2000;8:128-34.
52. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs. 1995;22(4):628-37.
53. Sanghera IS, Franklin BD, Dhillon S. The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care unit. Anaesthesia. 2007;62(1):53-61.
54. Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors and near errors reported by hospital staff nurses. Appl Nurs Res. 2004;17(4):224-30.
55. Taylor JA, Loan LA, Kamara J, et al. Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics. 2008;121(1):123-8.
56. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43.
57. Cullen D, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: a comparitive study of intensive care and general care units. Crit Care Med. 1997;25(8):1289-97.
58. Balas MC, Scott LD, Rogers AE. Frequency and type of errors and near errors reported by critical care nurses. Can J Nurs Res. 2006;38(2):24-41.
59. Colligan L, Bass EJ. Interruption handling strategies during paediatric medication administration. BMJ Qual Saf. 2012;21(11):912-7.
60. Stetina P, Groves M, Pafford L. Managing medication errors - a qualitative study. Medsurg Nurs. 2005;14(3):174-8.
61. Haghenbeck KT. Critical care nurses' experiences when technology malfunctions. J N Y State Nurses Assoc. 2005(Spring-Summer);36(1):13-9.
62. Nichols P, Copeland TS, Craib IA, et al. Learning from error: identifying contributory causes of medication errors in an Australian hospital. Med J Aust. 2008;188(5):276-9.
63. Reid-Searl K, Moxham L, Happell B. Enhancing patient safety: the importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students. Int J Nurs Pract. 2010;16(3):225-32.
64. Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33.
65. Gill F, Corkish V, Robertson J, et al. An exploration of pediatric nurses' compliance with a medication checking and administration protocol. J Spec Pediatr Nurs. 2012;17(2):136-46.
66. Manias E, Aitken R, Dunning T. Medication management by graduate nurses: before, during and following medication administration. Nurs Health Sci. 2004;6(2):83-91.
67. Baker HM. Rules outside the rules for administration of medication: a study in New South Wales, Australia. Image J Nurs Sch. 1997;29(2):155-8.
68. Gordon PC, Llewellyn RL, James MF. Drug administration errors by South African anaesthetists - a survey. S Afr Med J. 2006;96(7):630-2.
69. Llewellyn RL, Gordon PC, Wheatcroft D, et al. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care. 2009;37(1):93-8.
70. Labuschagne M, Robbetze W, Rozmiarek J, et al. Errors in drug administration by anaesthetists in public hospitals in the Free State. S Afr Med J. 2011;101(5):324-7.
71. Gordon PC. Wrong drug administration errors amongst anaesthetists in a South African teaching hospital. South Afr J Anaesth Analg. 2004;10(2):7-8.
72. Webster CS, Merry AF, Larsson L, et al. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29(5):494-500.
73. McBride-Henry K, Foureur M. A secondary care nursing perspective on medication administration safety. J Adv Nurs. 2007;60(1):58-66.
74. Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6):728-35.
75. Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth. 2001;48(2):139-46.
76. Hall KW, Ebbeling P, Brown B, et al. A retrospective-prospective study of medication errors: basis for an ongoing monitoring program. Can J Hosp Pharm. 1985;38(5):141-3,146.
77. Chua SS, Tea MH, Rahman MH. An observational study of drug administration errors in a Malaysian hospital (study of drug administration errors). J Clin Pharm Ther. 2009;34(2):215-23.
78. Chua SS, Chua HM, Omar A. Drug administration errors in paediatrics wards: a direct observation approach. Eur J Paediatr. 2010;169(5):603-11.
79. van Gijssel-Wiersma DG, van den Bemt PM, Walenbergh-van Veen MC. Influence of computerised medication charts on medication errors in a hospital. Drug Saf. 2005;28(12):1119-29.
80. Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. Prevalence of medication administration errors in two medical units with automated prescription and dispensing. J Am Med Inform Assoc. 2012;19(1):72-8.
81. Rai E. Medication errors in a tertiary care institution - an audit. J Anaesth Clin Pharmacol. 2010;26(3):371-4.
82. Tang FI, Sheu SJ, Yu S, et al. Nurses relate the contributing factors involved in medication errors. J Clin Nurs. 2007;16(3):447-57.
83. Vazin A, Delfani S. Medication errors in an internal intensive care unit of a large teaching hospital: a direct observation study. Acta Med Iran. 2012;50(6):425-32.
84. Agalu A, Ayele Y, Bedada W, et al. Medication administration errors in an intensive care unit in Ethiopia. Int Arch Med. 2012;5(1):15.
85. Kim KS, Kwon SH, Kim JA. Nurses' perceptions of medication errors and their contributing factors in South Korea. J Nurs Manag. 2011;19(3):346-53.
86. Zhang Y, Dong YJ, Webster CS, et al. The frequency and nature of drug administration error during anaesthesia in a Chinese hospital. Acta Anaesthesiol Scand. 2013;57(2):158-64.
87. Fasting S, Gisvold SE. Adverse drug errors in anaesthesia, and the impact of coloured syringe labels. Can J Anaesth. 2000;47(11):1060-7.
88. Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136-43.
89. No authors listed. ASHP Standard definition of a medication error. Am J Hosp Pharm. 1982;39(2):321.
90. No authors listd. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50(2):305-14.
91. Bryman A. Social research methods. 4th rev ed. New York: Oxford University Press; 2012.
92. Dornan T, Ashcroft D, Heathfield H, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. General Medical Council 2009. Available from URL http://www.gmc-uk.org/FINAL-Report-prevalence-and-causes-of-prescribing-errors. pdf-28935150.pdf. Accessed 2013 July 2.
93. Paulhus D. Measurement and control of response bias. In: Robinson J, Shaver P, Wrightsman L, editors. Measures of personality and social psychological attitudes. San Diego: Academic Press; 1991. p. 17-59.
94. Nguyen C, Côté J, Lebel D, et al. The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication administration process on the floor. J Eval Clin Pract. 2013;19(1):192-9.
95. Shebl N, Franklin B, Barber N, et al. Failure mode and effects analysis: views of hospital staff in the UK. J Health Serv Res Policy. 2012;17(1):37-43.
96. Young J, Slebodnik M, Sands L. Bar code technology and medication administration error. J Patient Saf. 2010;6(2):115-20.
97. Wulff K, Cummings GG, Marck P, et al. Medication administration technologies and patient safety: a mixed-method systematic review. J Adv Nurs. 2011;67(10):2080-95.
98. Hsaio GY, Chen IJ, Yu S, et al. Nurses' knowledge of high-alert medications: instrument development and validation. J Adv Nurs. 2010;66(1):177-90.
99. Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child. 2012;97(9):833-7.
100. Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. Jt Comm J Qual Patient Saf. 2012;38(3):127-34.
101. Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two paediatric hospitals. BMJ Qual Saf. 2012;21(5):408-15.
102. Reckmann MH, Westbrook JI, Koh Y, et al. Does computerised provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med Inform Assoc. 2009;16:613-23.
103. Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care. 2007;16:279-84.
104. Hughes RG (ed). Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: US Agency for Healthcare Research and Quality; 2008.
105. Potter P, Wolf L, Boxerman S, et al. Understanding the cognitive work of nursing in the acute care environment. J Nurs Adm. 2005; 35(7-8):327-35.
106. Biron A. Medication administration complexity, work interruptions, and nurses' workload as predictors of medication administration errors [thesis]. Canada: McGill University; 2009.
107. Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Nursing home error and level of staff credentials. Clin Nurs Res. 2007;16(1):72-8.
108. Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-9097.
109. Buchini S, Quattrin R. Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project. J Nurs Manag. 2012;20(3):326-34.
110. Aspden P, Wolcott JA, Bootman JL, et al., editors. Preventing medication errors. Washington DC: National Academies Press; 2007.
111. Vincent C. Patient safety. 2nd rev ed. Chichester: Wiley-Blackwell; 2010: 273.