Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

• Published in: Drug safety 2013-11, Vol.36 (11), p.1045-1067
• Main Authors: Keers, Richard N., Williams, Steven D., Cooke, Jonathan, Ashcroft, Darren M.
• Format: Article
• Language: English
• Subjects: Accidents; Assia; Biological and medical sciences; Drug Safety and Pharmacovigilance; Drug toxicity and drugs side effects treatment; Hospitals; Medical errors; Medical sciences; Medicine; Medicine & Public Health; Methods; Miscellaneous (drug allergy, mutagens, teratogens...); Nursing; Patient safety; Pharmacology. Drug treatments; Pharmacology/Toxicology; Studies; Systematic Review
• ISSN: 0114-5916; 1179-1942
• DOI: 10.1007/s40264-013-0090-2

Background Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence. Objective This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings. Data Sources Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013. Study Selection Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail. Data Appraisal and Synthesis Methods A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason’s model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used. Results Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of qu