Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review
OBJECTIVES: Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors. METHODS: A systematic review adhering to PRISMA guidelines was conducted. We sear...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
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Lippincott Williams & Wilkins
2021
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Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612891/ https://www.ncbi.nlm.nih.gov/pubmed/32011427 http://dx.doi.org/10.1097/PTS.0000000000000632 |
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author | Kuitunen, Sini Niittynen, Ilona Airaksinen, Marja Holmström, Anna-Riia |
author_facet | Kuitunen, Sini Niittynen, Ilona Airaksinen, Marja Holmström, Anna-Riia |
author_sort | Kuitunen, Sini |
collection | PubMed |
description | OBJECTIVES: Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors. METHODS: A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis. RESULTS: Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality. CONCLUSIONS: Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed. |
format | Online Article Text |
id | pubmed-8612891 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Lippincott Williams & Wilkins |
record_format | MEDLINE/PubMed |
spelling | pubmed-86128912021-11-29 Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review Kuitunen, Sini Niittynen, Ilona Airaksinen, Marja Holmström, Anna-Riia J Patient Saf Original Studies OBJECTIVES: Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors. METHODS: A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis. RESULTS: Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality. CONCLUSIONS: Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed. Lippincott Williams & Wilkins 2021-12 2020-02-03 /pmc/articles/PMC8612891/ /pubmed/32011427 http://dx.doi.org/10.1097/PTS.0000000000000632 Text en Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) (https://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. |
spellingShingle | Original Studies Kuitunen, Sini Niittynen, Ilona Airaksinen, Marja Holmström, Anna-Riia Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title | Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title_full | Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title_fullStr | Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title_full_unstemmed | Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title_short | Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review |
title_sort | systemic causes of in-hospital intravenous medication errors: a systematic review |
topic | Original Studies |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612891/ https://www.ncbi.nlm.nih.gov/pubmed/32011427 http://dx.doi.org/10.1097/PTS.0000000000000632 |
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