[Link]/10.5380/ce.v26i0.79446 Cogit. Enferm.
2021, v26:e79446
REVIEW
STRATEGIES FOR REDUCING MEDICATION ERRORS
DURING HOSPITALIZATION: INTEGRATIVE REVIEW
Claudia Regina de Barros Costa1
Sara Soares dos Santos2
Simone de Godoy2
Leila Maria Marchi Alves2
Ítalo Rodolfo Silva3
Isabel Amélia Costa Mendes2
ABSTRACT
Objective: to synthesize the knowledge related to strategies to reduce medication errors during the
hospitalization of adult patients. Method: integrative literature review carried out in October 2020
through the search for publications in electronic databases: Web of Science, Pubmed, Cumulative
Index of Nursing and Allied Health Literature, Latin American and Caribbean literature in Health
Sciences and Google Scholar. Results: sample composed of 12 studies, whose strategies for the
reduction of medication errors were presented according to the categories: involvement of the
clinical pharmacist in clinical activities, implementation of information technologies, educational
strategies mediated by simulation and games, and workload reduction. Conclusion: associated
with technologies, the involvement of the clinical pharmacist in the medical and nursing team will
result in improvements in the reduction of adverse medication events and in the quality of care
provided to the patient.
DESCRIPTORS: Medication errors; Patient Safety; Hospital Medication Systems; Safety
Management; Nursing Care.
HOW TO REFERENCE THIS ARTICLE:
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC. Strategies for reducing medication
errors during hospitalization: integrative review. Cogit. Enferm. [Internet]. 2021 [accessed “insert day, monh and
year”]; 26. Available from: [Link]
1
Universidade Federal de Mato Grosso. Sinop, MT, Brasil.
2
Universidade de São Paulo. Ribeirão Preto, SP, Brasil.
3
Universidade Federal do Rio de Janeiro. Macaé, RJ, Brasil.
Cogit. Enferm. 2021, v26:e79446
INTRODUCTION
International health organizations consider patient safety as a priority indicator of
quality of care. Global efforts target the reduction and control of the risks arising from
safety incidents(1). The events that cause harmful and preventable consequences include
medication errors. Identifying and reporting medication errors is essential to safeguard
patient safety(2), as they can occur at all stages of the drug use process: in the prescription,
dispensing and administration, in addition to situations of medication reconciliation, and in
improper patient monitoring(3).
Medication errors are preventable and considered one of the important causes of
health problems worldwide, as they result in high mortality rates, prolong the hospitalization
period, affect treatment, and drive up health care expenses(4). According to an analysis by
the World Health Organization (WHO), published in 2017, the global costs associated with
medication errors are approximately 42 billion USD per year(5-6).
This data on the costs of medication errors has generated global initiatives towards
a goal of reducing serious and avoidable medication-related harm by 50%, to the extent
that WHO’s Global Patient Safety Challenge elected “medication without harm” as its third
Global Challenge, aiming to expose and discuss the weaknesses in health systems and
establish strategies to prevent such events(5). Multiple factors trigger medication errors,
part of which originate in miscommunication among health professionals and management
and organization problems(7). Psychosocial factors play a crucial role in the emergence of
these errors though(8).
Medication errors can acknowledgedly bring about temporary or permanent patient
damage. The results deriving from these errors can be minimized or reversed though if the
error is identified early(9). Therefore, the US National Coordinating Council for Medication
Error Reporting and Prevention (NCC-MERP) recommends that health organizations
develop systems and processes to collect information necessary for analyzing reports of
medication errors as soon as possible after the event(9).
As important as early action to repair damage caused by medication errors is to
implement strategies to identify and minimize factors predisposing to risks. Several strategies
to prevent these errors have been studied and used in all stages of the medication use
chain, including as the use of health information technologies, which significantly reduce
risks(10).
Another widely disseminated strategy among nursing staff is the use of the “five rights
of medication administration”, updated to the “nine rights of medication administration”
(right patient, right drug, right route, right time, right dose, right documentation, right
action, right form and right response)(11-12). Despite the fact that they do not fully guarantee
the prevention of errors, their systematic adoption can significantly limit part of the events(12).
In view of the above, knowing strategies to reduce medication errors is essential and
can provide useful and necessary information for public and private hospitals to overcome
these problems by adopting effective practices that minimize harm to patients and the
system. In this context, this study aimed to synthesize knowledge related to strategies to
reduce medication errors during the hospitalization of adult patients.
METHOD
Integrative literature review study, developed to gather and synthesize research
results, in a systematic way, regardless of the design used. It was developed based on
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
the following stages: definition of the guiding question, search for primary studies in the
databases, extraction of data from studies, evaluation of selected primary studies, analysis
and synthesis of included studies, and presentation of the knowledge synthesis(13).
To formulate the guiding question of the research, the PICO(14) strategy was used,
whose acronym represents: P (population) - adult patient; I (intervention) - strategies to
prevent medication errors; C (comparison) - did not apply; and O (outcome) - medication
error reduction. Thus, the following question was obtained: what are the strategies used to
reduce medication errors during the hospitalization of adult patients?
The following inclusion criteria were adopted: studies that presented a strategy
for reducing medication errors during the hospitalization of adult patients, published in
Portuguese, English and Spanish, in a time frame between January 2015 and October
2020, in order to discuss the scientific evidence produced in the last five years. Articles
that did not answer the research question, those performed with pediatric patients, theses,
dissertations, editorials, review articles, opinions, reflections or comments, letters to the
editor, expanded abstracts and publications in annals of scientific events and books were
excluded.
The descriptors “Medication errors, Hospitalization, Patient safety and Medication
errors reduction” were used in English and combined with the Boolean operators OR and
AND in the databases.
The searches were carried out independently by two researchers, in October 2020, in
the following electronic databases: Web of Science, Pubmed, Cumulative Index of Nursing
and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health
Sciences (LILACS) and Google Scholar. The findings were 2,551 studies, seven of which
were available in the Web of Science, 2,535 na PubMed, six in CINAHL, three in LILACS
and none in Google Scholar.
After the search, the data was exported to the reference manager Web EndNote for
the deletion of duplicates. Twelve duplicate records were identified. Subsequently, two
independent reviewers read the titles and abstracts, who excluded 2,516 records that did
not answer the guiding question, totaling 23 articles for reading the full text. At this stage,
two reviewers disagreed on three articles, requiring the collaboration of a third reviewer
for the final decision, totaling a final sample of 12 articles included in the review (Figure 1).
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
Figure 1 - Identification flowchart of the primary studies included in the review. Ribeirão Preto, SP, Brazil,
2020
Source: Authors (2020).
To extract the data for the qualitative synthesis, a validated instrument was used(15)
and adapted for this research, which included: identification of the article, authorship, year,
language, methodological characteristics, data treatment, interventions and results related
to the reduction of medication errors during the hospitalization of adult patients. For each
study analyzed, a table was elaborated with the year of publication, the country, the place
of research, the journal and area of specialty and the level of evidence. To classify the
level of evidence, the seven-level evidence hierarchy was used(16). The synthesis of the
evidence was organized descriptively.
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
RESULTS
The Integrative review presented here resulted from 12 articles that met the previously
established inclusion criteria, ten of which were published in English and two in Portuguese
(Table 1).
Table 1 - Articles included in the integrative review, according to journal, country of publication, year of
publication, place of research, area of specialty of the journal and level of evidence. Ribeirão Preto, SP,
Brazil, 2020
Periodical / country of development / Research site Journal specialty / level of
year evidence
Therapeutics and Clinical Risk Teaching hospital Interdisciplinary (VI)
Management, China, 2015(17)
PloS One, France, 2015(18) Teaching hospital, orthopedic Interdisciplinary (VI)
surgical unit
Pharmacy Practice, USA, 2015(19) For-profit community hospital Pharmacy (IV)
affiliated with the health
system of the Hospital
Corporation of America (HCA)
Latin American Journal of Nursing (Rlae), Public hospital Nursing (VI)
Brazil, 2016(20)
European Journal of Hospital Pharmacy Teaching hospital, Hospital pharmacy (IV)
(EJHP), Denmark, 2016(21) hematological
Journal of Research in Pharmacy Practice Teaching hospital Pharmacy (VI)
(JRPP), Iran, 2017(22)
Epidemiology and Health, Iran, 2017(23) Teaching hospital Epidemiology and Public
Health (VI)
PLoS One, France, 2017(24) Teaching hospital Interdisciplinary (IV)
BMJ Quality Improvement Reports, Teaching hospital Health (III)
Netherlands, 2017(25)
Hospital Pharmacy, USA, 2018(26) Teaching hospital Pharmacy (IV)
Therapeutic Advances in Drug Safety, Teaching hospital Interdisciplinary (III)
Australia, 2019(27)
Einstein (São Paulo), Brazil, 2019(28) Teaching hospital Health (VI)
Source: Authors (2020).
Regarding the place where the studies were developed, in ten articles, the data
came from teaching hospitals affiliated to universities, one from a public hospital and one
from a for-profit community-based hospital. In addition, ten studies were conducted in a
single institution and two were multicenter studies.
Considering the year of publication, three articles were published in 2015, two in
2016, four in 2017, one in 2018 and two in 2019.
As for the specialty of the journal the articles were published in, four are from
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
interdisciplinary journals, three from pharmacy, two from general health, one from nursing,
one from hospital pharmacy and one from public health and epidemiology. In terms of the
levels of evidence, two articles were classified at level III, four at level IV and six at level VI.
Regarding the methodological detailing, only one of the selected articles adopted
a qualitative approach with Graneheim content analysis; the others used a quantitative
approach with cross-sectional design (one), observational before and after (two), prospective
cohort (two), retrospective cohort (two), quasi-experimental (two) and intervention (two).
The strategies to reduce medication errors identified included the incorporation of
electronic systems from the prescription to the medication administration, the collaboration
of the pharmacist and family members in the medication administration and reconciliation
process, the continuing education of the health team, as well as the use of a method based
on collaborative team effort for better performance in the medication administration
process (Table 2).
Table 2 - Articles included in the Integrative review according to the title and strategies found for reducing
medication errors. Ribeirão Preto, SP, Brazil, 2020 (continues)
Article title Strategies for reducing medication errors
Quality improvements in decreasing Three-and-a-half year intervention program focusing on
medication administration errors made by medication errors, aiming for institutional accreditation
nursing staff in an academic medical center by Joint Commission International (JCI)
hospital: a trend analysis during the journey to
Joint Commission International accreditation
and in the post-accreditation era(17)
Causes of Medication Errors in Intensive Care Computerized entry of the prescription order; identical
Units from the Perspective of Healthcare format for writing the prescription; permanent
Professionals(22) education to the health team; effective human resource
in care; collaboration of the pharmacist; involvement
of family/caregivers in the medication reconciliation
process in hospital.
Medication errors among nurses in teaching Reduction of the nursing team's workload and
hospitals in the West of Iran: what we need to implementation of permanent education programs for
know about prevalence, types, and barriers to the health team.
reporting(23)
An Observational Study of the Impact of a A Computerized Physician Order Entry (CPOE) system
Computerized Physician Order Entry System associated with verification by the clinical pharmacist.
on the Rate of Medication Errors in an
Orthopaedic Surgery Unit(18)
Improving medication safety: Development A multivariate model to predict potential medication-
and impact of a multivariate model-based related adverse events as a strategy to improve the
strategy to target high-risk patients(24) allocation of the clinical pharmacist and subsequent
patient safety.
The Role of Computerized Clinical Decision A support tool for clinical decision making incorporated
Support in Reducing Inappropriate into the Computerized Physician Order Entry (CPOE)
Medication Administration During Epidural system.
Therapy(26)
An automated medication system reduces An Automated Medication System - AMS integrates
errors in the medication administration electronic medication administration records (eMARs)
process: results from a Danish hospital and barcode-assisted automatic dispensing (BCMA).
study(21)
Strategies for reducing medication errors during hospitalization: integrative review
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Impact of pharmacy-led medication Involvement of the clinical pharmacist in the medication
reconciliation on medication errors during reconciliation process during hospitalization
transition in the hospital setting(19)
Pharmacist-assisted electronic prescribing Involvement of the clinical pharmacist in the medication
at the time of admission to an inpatient reconciliation process during hospitalization and
orthopaedic unit and its impact on medication electronic prescription using eMMS (electronic
errors: a pre- and post intervention study(27) medication management system) in hospitalized
orthopedic patients.
Experiences with Lean Six Sigma as Hospital Improvement Program, Lean Six Sigma.
improvement strategy to reduce parenteral Customized intervention for the problems: five-step
medication administration errors and cycle, DMAIC (define, measure, analyze, improve,
associated potential risk of harm(25) control), with team training, routine changes in the
medication administration process, posters and folders.
Implementing technologies to prevent Integration of various technologies in the medication
medication errors at a high-complexity chain in the prevention of medication errors.
hospital: analysis of cost and results(28)
Risk factors for medication errors in the Electronic prescription (EP) with support for clinical
electronic and manual prescription(20) decision making X manual prescription (MP), identifying
risk factors for medication errors.
Source: Authors (2020).
DISCUSSION
This integrative review allowed the identification of strategies to reduce medication
errors during hospitalization of adult patients. The countries where the analyzed and
synthesized studies were undertaken demonstrated great variation, showing the importance
and concern the theme represents and hospital institutions’ great interest in mitigating the
occurrence of medication errors.
The pharmacist’s involvement in the daily clinical activities at inpatient units stands
out, ranging from admission to discharge, acting in the medication reconciliation process
during hospitalization, monitoring and intervening in the entire medication administration
process. The pharmacist’s activities in clinical practice are fundamental with a view to rational
medication use, contributing to the achievement of expected therapeutic outcomes while
minimizing medication error risks(18-19,22,24,27).
It is important to recall that, in 1999, the report entitled “To err is human: building a
safer health system”, by the Institute of Medicine (US) Committee on Quality of Health Care
in America, described human errors in the health system and highlighted the importance of
the pharmaceutical professional in medication reconciliation and prescription(27).
Other studies also reveal the significant impact of pharmacists’ interventions on the
use of computerized electronic prescription (Computerized Physician Order Entry-CPOE),
and medication management systems (Electronic Medication Management System-
EMMS). With the support of these technological tools, improvements have been observed
in patients’ clinical outcomes due to the accuracy of the drug treatment, improvement in
patient safety with the prevention of adverse events and, consequently, cost savings(19,27).
The implementation and/or improvements of information technologies were the
most found strategies in the studies evaluated, showing reduction in the medication error
rates, facilitating interdisciplinary communication and reducing delays in the correction of
prescriptions(18,20-22,26-28).
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In some studies, the computerized physician order entry (CPOE) system was
incorporated into clinical decision support modules and the electronic medication
management system (EMMS). These support tools favored the integration of understandable
and reliable pharmaceutical information, enabled access to data on possible drug
interactions or adverse effects, enabling professionals to administer medications safely
and accurately. The authors of the studies indicate the use of technological tools to obtain
satisfactory results for patient safety, both in the reduction of incorrect medications and of
adverse drug events(26-27).
According to the studies, the CPOE favors the reading and understanding of the
prescription, reducing its illegibility and eliminating erasures. The CPOE focuses key
information on the prescription (route, dilution, dose, frequency), name of the active
ingredient, and complete prescriptions. In one of the studies, a decrease in cases of
allergies was verified. On the other hand, there was an increase in risk factors such as “lack
of verification” and “lack of identification of the prescribing professional’s professional
registration number”. It should be acknowledged, however, that when computerization
is well used, it promotes easy and accurate records by the health team professionals,
especially doctors and nurses, increasing patient safety and reducing risk factors for such
situations. Thus, the CPOE alone does not eliminate the possibility of medication errors(20).
Continuing education was listed as a strategy in the selected studies(17,22-23,25,28); when
conducted as a constant practice, it favors the prevention of errors and offers safety to the
professional(25).
Educational strategies mediated by simulation, games and others prove to be
important for improving multidisciplinary communication, developing the safety culture,
integrating the use of technological tools and also for reducing medication-related incident
rates(17,22). It is suggested that managers should increasingly explore and value this low-cost
strategy to prevent medication administration errors and ensure patient safety.
Among the studies analyzed, the reduction of the workload and sufficient nursing
staff dimensioning were reported as strategies in reducing medication errors(17,22-23). In a
study conducted in an intensive care unit, it was identified that the heavy workload due
to the large number of patients, in addition to fatigue, sleep and stress, aggravated the
occurrence of different errors in the medication administration process(23).
Appropriate staff dimensioning is fundamental for safe care, and managers and
the institution are responsible for granting favorable working conditions to the human
resources at the services. Appropriate workloads and staff dimensioning, in accordance
with the patients’ number and needs, play an important role in the reduction of medication
errors, as well as a lower incidence of occupational health problems(22-23).
Hospital quality programs were listed as a strategy to prevent medication errors
in the studies(17,25). Some intervention programs focusing on medication errors include
organizational, information technology, educational, and process optimization-based
measures. Programs such as the Joint Commission International (JCI) and the Lean Six
Sigma method are developed in hospital institutions, and can intensify the quality of
health systems, improve the organizational climate, satisfaction, safety and knowledge
of professionals and, consequently, increase their capacity and motivation to prevent
medication errors and achieve successful practices to improve the quality of health care.
The importance of this theme in nursing education should be highlighted, with a
view to efforts for future professionals to get to the job market prepared to guarantee the
quality of health systems, especially with regard to the ability to prevent medication errors.
Academic investments have been reported in the literature with scripts to assess safety in
medication administration by nursing students(29), as well as the patients’ involvement and
participation as stakeholders in watching over their own safety in the reception of care(30).
To the extent that better prepared professionals and increased health literacy become
available, we will have more favorable conditions for health organizations to be successful
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
in their quality and patient safety programs.
CONCLUSION
The findings showed that communication technologies in health care have become
important tools for the multiprofessional team, increasing the quality of care provided or
enhancing the reliability of the interventions needed.
Associated with the technologies, the pharmacist’s involvement in the daily activities
in the inpatient units, with the medical and nursing staff, will result in improvements in the
reduction of medication-related adverse events and in the quality of care.
In combination with these two strategies, quality-focused continuing education
programs are developed for the multiprofessional team, and the hospital management
needs to heed and commit to the employment conditions of its staff, the most important
capital of the institution it manages; workload reducation and sufficient nursing staff
dimensioning cannot be ignored when seeking to compose and elect strategies to reduce
medication errors.
The analysis of the selected studies highlights the need to continuously seek out the
results of studies undertaken in favor of ensuring patient safety and eliminating failures
in the medication administration process. The strategies listed in the studies are mutually
complementary and demonstrate the importance of multidisciplinary research on this topic.
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Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC
Cogit. Enferm. 2021, v26:e79446
Received: 17/02/2021
Approved: 03/08/2021
Associate editor: Luciana Alcântara Nogueira
Corresponding author:
Isabel Amélia Costa Mendes
Universidade de São Paulo – Ribeirão Preto, SP, Brasil
E-mail: iamendes@[Link]
Role of Authors:
Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for
the work - Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC; Drafting the work or revising it
critically for important intellectual content - Costa CR de B, Godoy S de, Alves LMM, Silva IR, Mendes IAC; Agreement to be
accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved - Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Mendes IAC. All authors
approved the final version of the text.
ISSN 2176-9133
Copyright © 2021 This is an open access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original article is properly cited.
Strategies for reducing medication errors during hospitalization: integrative review
Costa CR de B, Santos SS dos, Godoy S de, Alves LMM, Silva IR, Mendes IAC