Factors Contributing to Medication Administration Errors by Nurses and Strategies for Safer Practice: A Systematic Review

Background to Medication Administration Errors

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medicine is in the control of a health professional or patient. Errors can occur at prescribing, transcribing, dispensing, administration or monitoring. Medication administration errors are deviations between what was prescribed and what the patient receives, including the wrong drug, dose, route, rate or time, an omitted dose or a dose given without a valid prescription.

The scale of the problem is substantial. In an economic analysis for England, Elliott et al. (2021) estimated that around 237 million medication errors occur in the country each year. Most had little or no potential for harm, but around 66 million were potentially clinically significant, and avoidable adverse drug events were estimated to cause or contribute to 1,708 deaths and cost the NHS about £98 million a year. Around 54% of all errors were estimated to occur at the administration stage, which places nurses at the centre of efforts to improve medication safety.

Drug administration errors are also difficult to detect. Unlike prescribing errors, which leave a written record that pharmacists can review, many administration errors are invisible unless someone observes the nurse giving the medicine. Incident reports capture only a small fraction of medication administration errors, so researchers rely mainly on direct observation, in which a trained observer watches medication rounds and compares what was given with what was prescribed.

Search Strategy and Methods

Evidence for this example was identified through targeted searches of openly accessible bibliographic records, publisher websites and the reference lists of key reviews. Search terms combined keywords for errors (“medication administration errors”, “drug administration errors”, “medication errors”) with terms for nursing and safety (“nurs*”, “interruption*”, “bar-code”, “intravenous”, “medication safety”), joined with the Boolean operators AND and OR. A full systematic review for assessment would run the same strategy in CINAHL, PubMed/MEDLINE, the Cochrane Library and Embase and report the number of records screened in a PRISMA flow diagram.

Sources were eligible if they examined the frequency, causes or prevention of medication administration errors involving nurses in adult hospital settings. Systematic reviews and observational or intervention studies using direct observation were prioritised because they provide the most accurate estimates. Sources using any definition of medication administration errors were accepted, provided the definition was stated. Studies limited to prescribing or dispensing, studies in community or care home settings and studies relying solely on incident reports were excluded.

Eight sources published between 2010 and 2021 were included: four systematic reviews, three direct observation studies and one national economic analysis (Table 1). Each source was appraised with a checklist matched to its design, using the Critical Appraisal Skills Programme (CASP) tools, and data were extracted on setting, methods, error rates, contributing factors and interventions. Findings were then grouped into themes through a narrative synthesis, because the studies were too varied to pool statistically.

Key Findings on Medication Administration Errors

Three themes were identified: the frequency and nature of errors, the individual and system factors that contribute to them, and the strategies tested to prevent them. Table 1 summarises the included sources.

Author, year	Design	Setting and sample	Key finding
Westbrook et al. (2010)	Direct observation study	98 nurses, 4,271 doses; two Sydney hospitals	Interruptions in 53% of administrations; each interruption increased clinical errors by 12.7%.
Poon et al. (2010)	Before-and-after observational study	14,041 administrations; one US hospital	Bar-code verification: 41.4% fewer non-timing errors and 50.8% fewer potential adverse drug events.
Westbrook et al. (2011)	Direct observation study	568 intravenous doses; two Sydney hospitals	69.7% had at least one clinical error; experience reduced the risk of error.
Keers et al. (2013a)	Systematic review	Direct observation studies in hospitals	Nearly one in five doses given with an error; wrong-time errors the most common.
Keers et al. (2013b)	Systematic review	54 studies of causes	Slips and lapses most common; workload, interruptions, communication and equipment contributed.
Berdot et al. (2013)	Systematic review	52 studies of hospital inpatients	Median error rate 10.5% excluding wrong-time errors; most errors of minor clinical impact.
Raban and Westbrook (2014)	Systematic review	10 studies of interruption interventions	Weak evidence that interventions reduce interruptions; very limited evidence on errors.
Elliott et al. (2021)	Economic analysis	National estimates, England	About 237 million errors a year; 54% at administration; 1,708 related deaths.

Theme 1: How Common Are Medication Administration Errors?

Direct observation studies consistently show that errors at the bedside are common. In a systematic review of observational studies, Keers et al. (2013a) found that nearly one in five doses in hospital was given with an error, with wrong-time errors forming the largest group. When timing errors were excluded, error rates were lower but still important. A separate systematic review of 52 studies by Berdot et al. (2013) reported a median error rate of 10.5% of opportunities for error when wrong-time errors were excluded, although the range between studies was wide.

Intravenous medicines carry particular risk. In an observational study of 568 intravenous administrations on six wards in two Australian teaching hospitals, Westbrook et al. (2011) found that 69.7% involved at least one clinical error, most often the wrong rate of administration, and that a quarter of these errors were rated as serious. Errors were also linked to procedural failures such as not checking patient identity or not using aseptic technique. Berdot et al. (2013) found that most drug administration errors had minor clinical consequences, but the potential for harm is greatest with intravenous and high-risk medicines.

Differences in definitions and methods make comparisons difficult. Studies vary in whether they count wrong-time errors, how they define a timing error and whether they include intravenous preparation. These differences explain much of the variation in reported rates. However, the overall pattern across reviews is consistent: medication administration errors are frequent, most cause little harm, and a minority have the potential for serious consequences.

Theme 2: Individual and System Factors

The causes of errors are complex. In a systematic review of 54 studies, Keers et al. (2013b) used Reason’s model of accident causation to classify causes. Slips and lapses, such as selecting the wrong product or forgetting a dose, were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate deviations from procedures. These acts were shaped by underlying conditions, including poor written communication, problems with the supply and storage of medicines, high workload, faulty or inaccessible equipment, patient acuity, staff fatigue and stress, and interruptions.

Interruptions have received particular attention. In an observational study of 98 nurses giving 4,271 doses in two Sydney hospitals, Westbrook et al. (2010) found that interruptions occurred in just over half of all administrations. Each interruption was associated with a 12.7% increase in clinical errors and a 12.1% increase in procedural failures, and the risk of a major error doubled when nurses were interrupted four times. These findings show how ordinary features of ward work can undermine medication safety.

Many interruptions come from colleagues, patients and relatives, and some are clinically necessary, for example when a patient deteriorates during a medication round. Nurses in the studies reviewed were often expected to give medicines while also answering telephones, admitting patients and responding to call bells. This suggests that medication administration errors linked to interruptions reflect the way nursing work is organised, not simply a lack of concentration, and that solutions must address ward routines as well as individual behaviour.

Experience and knowledge also matter. Westbrook et al. (2011) found that each additional year of nursing experience, up to six years, reduced the risk of an intravenous error by around 11% and of a serious error by more than 18%. Newly qualified nurses may therefore need additional support when giving complex medicines. However, Keers et al. (2013b) emphasised that most medication administration errors arise from the interaction of several system factors rather than from individual incompetence.

Theme 3: Strategies for Safer Practice

Technology has shown some of the clearest benefits. In a large before-and-after study, Poon et al. (2010) found that bar-code verification at the bedside, combined with an electronic medication administration record, was associated with a 41.4% reduction in non-timing errors, a 50.8% reduction in potential adverse drug events and fewer timing errors. Transcription errors were eliminated. However, the study took place in a single hospital, and nurses bypassed the scanning step in about one in five administrations, showing that technology depends on how it is used.

Efforts to reduce interruptions have produced less convincing results. In a systematic review of ten studies, Raban and Westbrook (2014) found weak evidence that interventions such as “do not disturb” tabards, quiet zones and protocols borrowed from aviation reduced interruptions, and very limited evidence that they reduced medication errors. No study used a controlled design. The authors cautioned that some interruptions are necessary for patient care and that hospitals should evaluate such interventions carefully before adopting them.

Discussion

This review shows that medication administration errors are a frequent and largely system-driven problem. Observation studies suggest that between one in ten and one in five doses involve an error, and that intravenous administration carries a much higher risk. Most errors cause little or no harm, but the sheer volume of doses given in hospitals means that even a small proportion of serious errors adds up to considerable harm, as the national estimates of Elliott et al. (2021) illustrate.

A further point concerns how medication administration errors are counted and learned from. Because most errors are detected only through direct observation, incident reporting systems greatly underestimate their frequency. Wards that report many errors may in fact have a more open safety culture than wards that report few. Managers should therefore interpret incident data with caution and use observation, audit and conversations with staff to understand where medication administration errors occur and why. A just culture, in which nurses can report mistakes without fear of unfair blame, is a precondition for this kind of learning.

The evidence supports a systems approach to medication safety. The causes identified by Keers et al. (2013b), including workload, interruptions, poor communication and equipment problems, lie largely outside the control of individual nurses. Strategies that redesign the system, such as bar-code verification, appear more effective than those that rely on individuals to resist distraction. This is consistent with wider patient safety thinking, which holds that errors are best prevented by making the right action easy and the wrong action difficult.

At the same time, technology is not a complete solution. Poon et al. (2010) showed that nurses bypassed bar-code scanning when it conflicted with workflow, and new systems can introduce new types of error. The weak evidence for interruption-reduction interventions (Raban & Westbrook, 2014) also suggests that apparently simple changes may not work as intended. Successful strategies are likely to combine technology with attention to staffing, training, ward design and a culture in which nurses feel safe to report errors and near misses.

The evidence base has limitations. Most studies came from teaching hospitals in high-income countries, observational designs dominated, and definitions of error varied widely. The presence of an observer may change nurses’ behaviour, possibly underestimating error rates. Few studies measured actual harm to patients. This review relied on openly accessible, English-language sources and did not involve independent double screening, which a full systematic review would require. Future studies should use controlled designs and report patient outcomes alongside drug administration errors.

Implications of Medication Administration Errors Evidence for Practice

For adult nurses, the evidence on medication administration errors supports careful checking of the patient’s identity, prescription and allergy status before every dose, particular care with intravenous medicines and double-checking of high-risk drugs according to local policy. Nurses should minimise avoidable interruptions during medication rounds where possible, use bar-code scanning consistently where it is available and report errors and near misses so that the system can learn. Newly qualified nurses should be supported to build competence with complex medicines.

Patients can also act as a safety check. Explaining what each medicine is for, encouraging patients to question a tablet that looks unfamiliar and involving them in the timing of doses such as insulin or analgesia all create an additional barrier to error. Clear handover of time-critical medicines, accurate documentation of omitted doses and prompt escalation when a dose cannot be given further reduce the risk that errors pass unnoticed between shifts.

Managers should focus on the system conditions that make errors more likely, including staffing, workload, equipment and the storage of medicines. Safe administration is especially important for patients with type 2 diabetes, where insulin errors can cause serious harm, and for surgical patients on enhanced recovery pathways, whose analgesia and antibiotics must be given on time. It also supports the prevention of hospital-acquired infections and the safe management of acute and chronic pain.

Conclusion

This systematic review examined the frequency, causes and prevention of medication administration errors in adult hospital settings. The evidence shows that errors are common, that intravenous medicines carry the greatest risk and that most errors arise from the interaction of individual actions with system factors such as workload, interruptions, communication and equipment.

Reducing medication administration errors requires both careful individual practice and safer systems. Bar-code verification has the strongest evidence among the strategies reviewed, while interventions to reduce interruptions remain unproven. Nurses can contribute by checking carefully, reporting openly and helping to redesign the processes they use every day, but lasting improvement depends on organisations that invest in staffing, technology and a just safety culture.

References

Berdot, S., Gillaizeau, F., Caruba, T., Prognon, P., Durieux, P., & Sabatier, B. (2013). Drug administration errors in hospital inpatients: A systematic review. PLoS ONE, 8(6), e68856. https://doi.org/10.1371/journal.pone.0068856

Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96–105. https://doi.org/10.1136/bmjqs-2019-010206

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013a). Prevalence and nature of medication administration errors in health care settings: A systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237–256. https://doi.org/10.1345/aph.1R147

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013b). Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Safety, 36(11), 1045–1067. https://doi.org/10.1007/s40264-013-0090-2

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698–1707. https://doi.org/10.1056/NEJMsa0907115

Raban, M. Z., & Westbrook, J. I. (2014). Are interventions to reduce interruptions and errors during medication administration effective?: A systematic review. BMJ Quality & Safety, 23(5), 414–421. https://doi.org/10.1136/bmjqs-2013-002118

Westbrook, J. I., Rob, M. I., Woods, A., & Parry, D. (2011). Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Quality & Safety, 20(12), 1027–1034. https://doi.org/10.1136/bmjqs-2011-000089

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683–690. https://doi.org/10.1001/archinternmed.2010.65