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Annu Rev Nurs Res. 2006;24:19-38.

Medication-related errors: a literature review of incidence and antecedents.

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  • 1School of Nursing, University of Colorado at Denver and Health Sciences, USA.

Abstract

Patient safety has become a major concern for both society and policymakers. Since nurses are intimately involved in the delivery of medications and are ultimately responsible during the medication administration phase, it is important for nursing to understand factors contributing to medication administration errors. The purpose of this chapter is to identify the incidence of these errors and the associated factors in an attempt to better understand the problem and lessen future error occurrence. Literature review revealed both active failures and latent conditions established in Reason's theory remain prevalent in current literature where active failures often display themselves in the form of incorrect drug calculations, lack of individual knowledge, and failure to follow established protocol. Latent conditions are evidenced as time pressures, fatigue, understaffing, inexperience, design deficiencies, and inadequate equipment and may lie dormant within a system until combined with active failures to create opportunity for error. Although medication error research has shifted in emphasis toward identification of system problems inherent in error occurrence, no one force emerges as a clear antecedent, reinforcing the need for further research and replication of existing studies with emphasis placed on more dependable reporting measures through which nurses are not threatened by reprisal.

PMID:
17078409
[PubMed - indexed for MEDLINE]
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