Credentials of Corresponding Author
PhD, RNC, CNE
In the United States, medication errors result in at least one death each day and injure over 1 million people annually (World Health Organization, 2017). The majority of medication errors occur during the administration stage; nurses are often responsible for administering medication to patients in healthcare settings. Thus, nurses’ perceptions of causes of medication errors can provide valuable guidance for the development of interventions aimed to mitigate errors.
The purpose of this review was to present a synthesis of qualitative research findings around perceived causes of medication administration errors as reported by nurses. Qualitative research can capture detailed descriptions of perceived causes of medication administration errors that can create a better understanding of this critical patient safety issue.
Publications from 2000 to February 2019 were searched using four electronic databases. Inclusion criteria were articles that (1) presented results from studies that used a qualitative or mixed methods design, (2) reported qualitative data on nurses’ perceived causes of medication administration errors in healthcare settings, and (3) were published in the English language.
Results of literature search
Nurses’ perceived causes of errors were categorized as knowledge-based, personal, and contextual factors. The primary knowledge-based factor was a lack of medication knowledge. Personal factors included fatigue and complacency. Contextual factors included heavy workloads and interruptions.
Synthesis of evidence
Contextual factors were reported in all the studies reviewed and were often interconnected with personal and knowledge-based factors. Causes of medication administration errors are perceived by nurses to be multifactorial and interconnected and often stem from systems (i.e., contextual) issues.
Implications for practice
Multifactorial interventions aimed at mitigating medication errors are required with an emphasis on systems changes. Findings in this review can be used to guide efforts aimed at identifying and modifying factors contributing to medication administration errors.
Nurses' Perceived Causes of Medication Administration Errors