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...

Descripción completa

Detalles Bibliográficos
Autores principales: Kuitunen, Sini, Niittynen, Ilona, Airaksinen, Marja, Holmström, Anna-Riia
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2021
Materias:
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
_version_ 1784603533564182528
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
work_keys_str_mv AT kuitunensini systemiccausesofinhospitalintravenousmedicationerrorsasystematicreview
AT niittynenilona systemiccausesofinhospitalintravenousmedicationerrorsasystematicreview
AT airaksinenmarja systemiccausesofinhospitalintravenousmedicationerrorsasystematicreview
AT holmstromannariia systemiccausesofinhospitalintravenousmedicationerrorsasystematicreview