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J Nurs Manag. 2009 Sep;17(6):679-97. doi: 10.1111/j.1365-2834.2009.00995.x.

A literature review of the individual and systems factors that contribute to medication errors in nursing practice.

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  • 1School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.



This paper reports a review of the empirical literature on factors that contribute to medication errors.


Medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors to deliver safe and ethical care to patients.


The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2007 using the keywords medication errors, medication management, medication reconciliation, medication knowledge and mathematical skills, and reporting medication errors. RESULTS Contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include medication reconciliation, the types of drug distribution system, the quality of prescriptions, and deviation from procedures including distractions during administration, excessive workloads, and nurse's knowledge of medications.


It is imperative that managers implement strategies to reduce medication errors including the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. Systematic approaches to medication reconciliation can also reduce medication error significantly. Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors. Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error. The health care industry can benefit from learning from other high-risk industries such as aviation in the prevention and management of systems errors.

[PubMed - indexed for MEDLINE]
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