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

Richard N Keers; Steven D Williams; Jonathan Cooke; Darren M Ashcroft

Review

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

September 18, 2013

Keers RN, Williams SD, Cooke J, et al. Drug Saf. 2013;36(11):1045-67.

View more articles from the same authors.

This systematic review identified several systems causes of medication administration errors, including interruptions, communication breakdowns, fatigue, and overall workload. A recent review found only limited evidence supporting strategies to prevent medication administration errors.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

March 27, 2013

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

April 1, 2015

Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review.

June 25, 2014

Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?

September 23, 2009

Retrospective analysis of medication incidents reported using an on-line reporting system.

December 13, 2006

Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review.

September 13, 2017

Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.

January 16, 2013

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.

June 12, 2019

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

Risk factors for hospital admissions associated with adverse drug events.

August 28, 2013

Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour.

September 9, 2015

Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals.

August 26, 2015

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

July 31, 2019

Learning from the design, development and implementation of the Medication Safety Thermometer.

February 8, 2017

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Psychosocial influences on safety climate: evidence from community pharmacies.

December 14, 2011

An investigation of occupational subgroups with respect to patient safety culture.

March 14, 2012

Exploring the human factors of prescribing errors in paediatric intensive care units.

March 27, 2019

Prevalence of adverse drug events in ambulatory care: a systematic review.

July 27, 2011

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Primary care medication safety surveillance with integrated primary and secondary care electronic health records: a cross-sectional study.

July 22, 2015

Identifying potential prescribing safety indicators related to mental health disorders and medications: a systematic review.

August 14, 2019

Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.

August 22, 2018

Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies.

May 23, 2018

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

Medication safety in community pharmacy: a qualitative study of the sociotechnical context.

December 2, 2009

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.

February 6, 2019

Preventable medication harm across health care settings: a systematic review and meta-analysis.

February 17, 2021

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

November 25, 2015

Pharmacist work stress and learning from quality related events.

November 9, 2016

Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.

May 8, 2019

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study.

October 22, 2014

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Development of the pharmacy safety climate questionnaire: a principal components analysis.

March 11, 2009

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components.

September 17, 2014

February 2, 2022

Safety culture assessment in community pharmacy: development, face validity, and feasibility of the Manchester Patient Safety Assessment Framework.

December 21, 2005

Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review.

July 22, 2020

The relationships among work stress, strain and self-reported errors in UK community pharmacy.

March 19, 2014

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.

October 21, 2020

Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.

August 9, 2006

Risk of adverse drug events by patient destination after hospital discharge.

September 21, 2005

Patient safety in healthcare preregistration educational curricula: multiple case study-based investigations of eight medicine, nursing, pharmacy and physiotherapy university courses.

June 19, 2013

Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals.

October 10, 2007

TeamSTEPPS for health care risk managers: improving teamwork and communication.

August 10, 2016

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

November 13, 2019

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework of Acceptability.

November 9, 2022

Using the patient safety huddle as a tool for high reliability.

April 4, 2018

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care.

October 28, 2015

Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.

March 27, 2019

A system analysis of a suboptimal surgical experience.

February 4, 2009

Medication errors in community pharmacies: the need for commitment, transparency, and research.

February 20, 2019

Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre.

October 17, 2007

Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.

September 9, 2009

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication.

February 26, 2014

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Effect of communication errors during calls to an antimicrobial stewardship program.

March 26, 2008

Doctors' handovers in hospitals: a literature review.

March 2, 2011

An innovative approach to the surgical time out: a patient-focused model.

June 29, 2016

The Veterans Affairs root cause analysis system in action.

March 27, 2005

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations.

April 25, 2012

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

Patient safety: do nursing and medical curricula address this theme?

June 1, 2005

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

August 15, 2007

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial.

May 23, 2012

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

January 30, 2005

A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training.

September 2, 2015

Seasoned surgeons assessed in a laparoscopic surgical crisis.

May 13, 2009

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

August 7, 2013

Online medication error graphic reports: a pilot in North Carolina nursing homes.

June 15, 2011

Reducing accidental extubation in neonates.

March 5, 2008

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.

August 22, 2007

Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis.

January 11, 2017

Adverse events in healthcare: learning from mistakes.

September 3, 2014

The SAGES FUSE program: bridging a patient safety gap.

October 22, 2014

Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's hospital: targeted interventions to increase the rate of reporting.

October 11, 2017

Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.

October 17, 2018

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

Medication errors in the outpatient setting: classification and root cause analysis.

March 21, 2007

Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system.

April 25, 2018

Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital?

July 9, 2008

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

December 15, 2010

Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.

November 8, 2006

Improving patient safety in radiotherapy by learning from near misses, incidents and errors.

August 1, 2007

Management reasoning: beyond the diagnosis.

May 23, 2018

Managing competing organizational priorities in clinical handover across organizational boundaries.

January 21, 2015

Improving hospital safety culture for falls prevention through interdisciplinary health education.

December 23, 2020

Professionalism lapses and adverse childhood experiences: reflections from the island of last resort.

August 14, 2019

Inside a closed-loop medication strategy: medication management targets stages in which errors occur, step by step.

March 6, 2005

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Surgeons don't know what they don't know about the safe use of energy in surgery.

June 20, 2012

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.

August 29, 2007

Association between Leapfrog safe practices score and hospital mortality in major surgery.

November 30, 2011

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

July 28, 2010

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

Related Resources

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis.

December 14, 2022

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

March 30, 2022

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

Medication administration and interruptions in nursing homes: a qualitative observational study.

July 11, 2018

Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature.

January 10, 2018

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

July 19, 2017

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

February 15, 2017

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

August 24, 2016

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

July 20, 2016

Towards international consensus on patient harm: perspectives on pressure injury policy.

June 8, 2016

Nursing strategies to increase medication safety in inpatient settings.

May 25, 2016

Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review.

May 25, 2016

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

September 23, 2015

Interruptions and medication administration in critical care.

July 29, 2015

Factors contributing to Registered Nurse medication administration error: a narrative review.

March 18, 2015

Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students.

December 10, 2014

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components.

September 17, 2014

Interruptions and multi-tasking: moving the research agenda in new directions.

September 10, 2014

From harm to hope and purposeful action: what could we do after Francis?

July 23, 2014

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety.

May 21, 2014

Implementing the Safety Thermometer tool in one NHS trust.

April 16, 2014

The relationship between patient safety culture and patient outcomes: a systematic review.

April 2, 2014

Medication administration errors in hospitals—challenges and recommendations for their measurement.

March 26, 2014

Team-training in healthcare: a narrative synthesis of the literature.

March 12, 2014

Augmenting health care failure modes and effects analysis with simulation.

March 5, 2014

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists.

February 26, 2014

Practices to prevent venous thromboembolism: a brief review.

February 19, 2014

Applying ethnography to the study of context in healthcare quality and safety.

January 22, 2014

A structured judgement method to enhance mortality case note review: development and evaluation.

December 4, 2013

See More About The Topic

Hospitals

Nurses

Health Care Executives and Administrators

Safety Scientists

General Internal Medicine

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site