Review

Predisposing Factors to Medication Errors by Nurses and

Prevention Strategies: A Scoping Review of Recent Literature
Fábio Coelho 1, * , Luís Furtado 1 , Natália Mendonça 2 , Hélia Soares 1 , Hugo Duarte 3,4 ,
Cristina Costeira 3,4 , Cátia Santos 3,4 and Joana Pereira Sousa 3,4

1 Department of Nursing, Mental Health, and Gerontology, School of Health, University of the Azores,
9700-042 Angra do Heroísmo, Portugal; luis.cr.furtado@uac.pt (L.F.); helia.m.soares@uac.pt (H.S.)
2 Flores Island Healthcare Unit, 9960-430 Flores Island, Portugal; natalia.lr.mendonca@azores.gov.pt
3 Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences, Polytechnic of
Leiria, 2411-090 Leiria, Portugal; cristina.costeira@ipleiria.pt (C.C.); catia.santos@ipleiria.pt (C.S.);
joana.sousa@ipleiria.pt (J.P.S.)
4 Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC),
3004-011 Coimbra, Portugal
* Correspondence: fabio.ad.coelho@uac.pt

Abstract: Medication errors have serious consequences and high costs for the patient and the
system. The treatment process and the care required for critically ill patients are complex, and these
patients are more vulnerable to errors and potential consequences. A scoping review using the JBI
methodology was conducted across PubMed, CINAHL, and MEDLINE databases and reported
by the PRISMA-ScR guidelines to explore strategies that can mitigate medication errors by nurses.
The search strategy focused on references published between January 2012 and April 2023. Sixteen
studies were included, and the results were organized into thematic areas. Medication errors by
nurses are in the areas of preparation, administration, and documentation; organizational, system-
related, procedural, personal, and knowledge and training factors are predisposing factors for errors;
educational intervention, verification and safety methods, organizational changes, and error reporting
are the strategic areas to mitigate medication error. The organization of the data could be different, as
Citation: Coelho, F.; Furtado, L.; it depends on the reviewers’ experience. Knowledge of the factors that cause medication errors and
Mendonça, N.; Soares, H.; Duarte, H.;
interventions to mitigate them make it possible to outline strategies to minimize their occurrence and
Costeira, C.; Santos, C.; Sousa, J.P.
achieve health gains. The protocol preceding this review has been registered in the Open Science
Predisposing Factors to Medication
Framework and published.
Errors by Nurses and Prevention
Strategies: A Scoping Review of
Keywords: interventions; nurses; medication errors; intensive care units
Recent Literature. Nurs. Rep. 2024, 14,
1553–1569. https://doi.org/10.3390/
nursrep14030117

Academic Editor: Daniel Bressington 1. Introduction

Received: 28 April 2024 Patient safety has emerged as a critical concern in healthcare, with medication errors
Revised: 21 June 2024 attracting significant attention due to their profound implications. Recent literature un-
Accepted: 24 June 2024 derscores the alarming frequency and severe consequences of these errors. For instance,
Published: 26 June 2024 studies estimate that medication errors affect approximately 1 in every 10 hospitalized
patients, with nearly 7% of these errors resulting in fatalities [1]. These errors not only
threaten patient lives but also impose exorbitant costs on healthcare systems, consuming
valuable resources that could be directed towards improving patient care [1–4].
Copyright: © 2024 by the authors.
Nurses are integral to the healthcare system, particularly in managing patient safety
Licensee MDPI, Basel, Switzerland.
during the medication process. This process is inherently complex and error-prone, encom-
This article is an open access article
distributed under the terms and
passing various stages from the selection and storage of medications to their prescription,
conditions of the Creative Commons
verification, preparation, administration, and monitoring [5,6]. Given their pivotal role,
Attribution (CC BY) license (https://
nurses are often the last line of defense against medication errors at the administration
creativecommons.org/licenses/by/ phase, which is noted for its high risk and correlation with adverse patient outcomes [7,8].
4.0/).

Nurs. Rep. 2024, 14, 1553–1569. https://doi.org/10.3390/nursrep14030117 https://www.mdpi.com/journal/nursrep

Nurs. Rep. 2024, 14 1554

Intensive care units (ICUs) present unique challenges due to the critical nature of patients
and the complexity of care required. Patients in ICUs typically undergo more frequent medi-
cation changes and receive a higher number of drugs, which significantly increases the risk of
errors. Studies have shown that in ICUs, medication errors occur at a rate of approximately
1.7 per patient per day, with severe or fatal errors disproportionately affecting these units [9,10].
These errors often result from high-risk procedures, complex medication regimens, and the
intense pace of work, which can overwhelm even the most diligent healthcare teams.
Given this backdrop, there is a pressing need to explore and understand the nuances of
medication errors within the ICU setting. It is recognized that there are literature reviews that
address issues related to error. However, other authors in this process have concluded that the
evidence for effective interventions to reduce medication errors by nurses in adult ICUs is limited
due to the inconsistency of the research design and methods [11]. Hence, the relevance of this
review. This scoping review is designed to delve into the literature to unearth the multifactorial
causes of medication errors and evaluate the effectiveness of interventions targeted at reducing
these errors. The review will specifically focus on the nursing role within ICUs, identifying
strategies that can enhance safety and minimize errors in medication administration [12,13].
The objectives of this review are to map out the contributory factors to medication
errors, to assess the effectiveness of existing interventions, and to explore innovative strate-
gies that can further mitigate these risks. The chosen methodological approach, a scoping
review, is particularly suited for this purpose as it allows for a broad exploration of complex
topics and facilitates the identification of key themes and gaps in the existing research.
The findings of this review are expected to contribute significantly to the body of
knowledge on patient safety in ICUs. By identifying effective practices and areas needing
improvement, this work aims to inform policy changes and guide the development of
targeted training programs for nurses and other healthcare professionals. Ultimately, the
insights garnered from this review will help shape interventions that are not only evidence-
based but also contextually adapted to the demanding environment of intensive care,
thereby enhancing patient safety and healthcare outcomes.

2. Methods
2.1. Research Question
To achieve the aim of this literature review study, a review question was formu-
lated and organized following the PCC mnemonic (“population”, “concept”, and “con-
text”) [14,15]. The study, therefore, sought to answer the following main question: Which
interventions prevent medication errors by nurses at any stage of the medication manage-
ment process in intensive care units?
Two supplementary questions further refine the scope of this review: (1) Which factors
predispose nurses to medication errors in intensive care units? and (2) Which consequences
and outcomes result from the occurrence of medication errors by nurses in intensive care units?

2.2. Study Design

The literature review followed the JBI methodology for scoping literature reviews [14,15].
This involved following a predetermined series of steps: (a) formulating the research question;
(b) identifying relevant sources of evidence; (c) selecting sources of evidence for inclusion;
(d) collecting/extracting data; and (e) grouping, summarizing, and reporting the findings.
The results were presented following the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines (Supplementary
Materials Tables S1 and S2) [16,17]. The literature review protocol was registered on the Open
Science Framework (https://doi.org/10.17605/OSF.IO/94KH3), and the protocol was also
published [18].

2.3. Inclusion Criteria

In line with the JBI framework for scoping reviews of the literature [14], our review
team established a comprehensive set of inclusion and exclusion criteria to guide the
Nurs. Rep. 2024, 14 1555

selection of studies. These criteria are essential for systematically assessing the records
retrieved from various databases and platforms, ensuring the relevance and specificity of
the included literature.
Participants/Population: This review focused on studies involving general care nurses,
clinical nurse specialists, and advanced practice nurses, without restrictions regarding the
length of professional practice or level of training. Excluded from this review were studies
that primarily involved physicians, pharmacists, nursing assistants, or nursing students.
However, for studies including multiple professional groups, data specifically pertaining
to nurses were extracted if clearly identified in the original document. Studies lacking clear
data on nurses or where such data could not be clarified by the authors were excluded.
Concept: The concept of intervention, often assumed as understood in various fields,
lacks a thorough exploration in the literature, leading to a superficial understanding of its
implications and effectiveness [19]. In this review, an intervention is defined as a specific
set of activities implemented to operationalize an activity with known dimensions [20].
An intervention is considered effective if it yields the expected outcomes for the target
population and context [21]. Medication errors are defined as failures in the medication
management process that result in inappropriate medication use or have the potential
to harm the patient [22]. Harm is described as temporary or permanent impairment of
physical, emotional, or psychological functions or structures of the body, including pain re-
quiring additional intervention [23]. Our review included studies addressing interventions
designed to prevent medication errors specifically by nurses, encompassing any strategy
aimed at mitigating such errors resulting from nursing actions
Context: This scoping review considered studies conducted in adult intensive care
units. Studies referring to intermediate care units or pediatric and neonatal intensive care
units were excluded. The exclusion of COVID-19-related studies is due to the heightened
risk of medication errors during pandemics, which may stem from systemic failures, inad-
equate preparedness, increased staff stress, attrition, and emerging clinical complexities,
necessitating distinct approaches to error mitigation [24].
Types of sources: The review included primary research employing quantitative,
qualitative, and mixed methods that met the inclusion criteria. Additionally, reports
and technical documents issued by recognized authorities such as government bodies,
professional organizations, or scientific societies were considered for inclusion. Literature
reviews, opinion texts, letters to the editor and editorials were excluded.

2.4. Search Strategy

The search strategy was meticulously structured in three stages following the JBI
framework for scoping literature reviews [14], aiming to encompass a wide range of
authoritative sources. This strategy targeted primary published studies, systematic reviews,
technical documents, and reports from well-recognized databases, government bodies,
professional organizations, scientific societies, and other entities with recognized expertise.
The period from January 2012 to April 2023 was selected to balance the scope of the review
with the capacity and availability of reviewers. While this timeframe excludes earlier studies,
it captures over a decade of relevant research, which we believe sufficiently represents recent
trends and advances without significantly impacting the quality or conclusions of the review.
Documents and studies in English and Portuguese were included to accommodate
the linguistic capabilities of the review team and the prevalence of these languages in the
relevant research.
An initial search specifically targeted literature reviews on the topic but failed to yield
results concerning interventions or factors that promote safety in medication practices
by nurses in ICUs. This search was conducted on the Open Science Framework (OSF® ,
Center for Open Science, Charlottesville, VA, USA) using the terms “nursing”, “medication
errors”, “intensive care unit”, and “review”, confirming the necessity and relevance of this
comprehensive review.
Nurs. Rep. 2024, 14 1556

A preliminary search was conducted in the PubMed electronic database to identify

pertinent articles by analyzing text in titles, abstracts, and the index terms used. Terms
from the natural vocabulary and descriptors identified during this preliminary phase were
then utilized to refine the search strategy applied in subsequent database searches.
Originally, our protocol included plans to search the Excerpta Medica Database (Em-
base); however, access limitations prevented its inclusion in the final search strategy, which
is noted as a limitation in the relevant section of this study. However, this strategy was ex-
panded to include the Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Complete and the Medical Literature Analysis and Retrieval System Online (MEDLINE),
both accessed via EBSCO (Supplementary Materials Table S3).
Searches were also conducted in the Open Access Scientific Repositories of Portugal
(RCAAP) and Dart-Europe for unpublished studies, complemented by searches on websites
of relevant professional associations, government bodies, and scientific societies to locate
additional supporting documents.
In the final stage of the search, the reference lists of all retained documents were
manually reviewed against the established inclusion and exclusion criteria to ensure com-
prehensiveness and relevance.
Table 1 shows the search strategy used in MEDLINE (via EBSCO), adapted to the other
databases used, adjusting it to their specificities.

Table 1. Search strategy conducted in the MEDLINE (via EBSCO).

Search No. Search Terms and Expressions Results

S1 MH “Nurses” OR TI nurs* OR AB nurs* 549,244
MH “Physicians” OR MH “Students+” OR MH “Nursing Assistants” OR TI
physician* OR AB physician* OR TI student* OR AB student* OR TI “nursing
assistant*” OR AB “nursing assistant*” OR TI “nursing student*” OR AB
S2 “nursing student*” OR TI “medical student*” OR AB “medical student*” OR TI 943,938
undergraduate OR AB undergraduate OR
TI “nursing aide*” OR AB “nursing aide*” OR TI “nursing assistant*” OR AB
“nursing assistant*”
S3 S1 NOT S2 454,611
MH “Treatment Errors” OR MH “Medication Errors” OR MH “Health Care
Errors” OR TI “nursing error*” OR AB “nursing error*” OR TI “medical error*”
OR AB “medical error*” OR TI “medication error*” OR AB “medication error*”
S4 2763
OR TI “medication administration error*” OR AB “medication administration
error*” OR TI “medication preparation error*” OR AB “medication
preparation error*”
MH “Intensive Care Units” OR MH “Respiratory Care Units” OR MH
“Coronary Care Units” OR
TI “intensive medical care*” OR AB “intensive medical care*” OR TI “intensive
care*” OR AB “intensive care*” OR TI ICU OR AB ICU OR TI “care, intensive”
S5 245,845
OR AB “care, intensive” OR TI “intensive care unit*” OR AB “intensive care
unit*” OR TI “intensive care medicine” OR AB “intensive care medicine” OR
TI “respiratory care unit*” OR AB “respiratory care unit*” OR TI “coronary
care unit*” OR AB “coronary care unit*”
MH “Intensive Care Units, Pediatric” OR MH “Intensive Care Units, Neonatal”
S6 OR TI “intensive care units, pediatric” OR AB “intensive care units, pediatric” 26,934
OR TI “intensive care units, neonatal” OR AB “intensive care units, neonatal”
S7 S5 NOT S6 218,911
S8 S3 AND S4 AND S7 198
S9 S3 AND S4 AND S7 from 2012–2023 126
Nurs. Rep. 2024, 14 1557

2.5. Study Selection

The obtained records were exported and imported into EndNote® v.20.4 software
(Clarivate Analytics, Philadelphia, PA, USA) for organization, analysis, and initial removal
of duplicates. A random sample of 25 documents was obtained. It was subjected to a
preliminary analysis by the reviewers, applying the defined eligibility criteria, followed by
a meeting for discrepancy analysis and clarification of these criteria [14,25]. The compliance
rate was over 75%.
The analysis, sorting, and selection process occurred in two distinct stages, carried out
on a Rayyan® platform (Qatar Computing Research Institute, Doha, Qatar). Initially, the
records were imported into the Rayyan® platform, where a secondary check for duplicates
was performed. Subsequently, screening by title and abstract, based on predefined inclusion
and exclusion criteria, was conducted by two independent, blinded reviewers. In a second
stage, studies deemed eligible for full-text review were re-imported into Rayyan® , where
they were once again assessed against the established eligibility criteria by two independent,
blinded reviewers. Standardized reasons for exclusion were documented and reported.
Any conflicts between reviewers were resolved through discussion or, if consensus could
not be reached, the intervention of a third reviewer. Due to the nature and purpose of the
review, the review team opted not to evaluate the methodological quality of the included
studies [26]. The corresponding author was contacted whenever the information provided
in the paper was insufficient or questionable. If the corresponding author did not respond
and the sought-after information was crucial for the reliability of the extracted data, the
study was excluded.

2.6. Data Extraction

The data were extracted utilizing a tool specifically designed for this purpose, devel-
oped within Microsoft Excel® (Microsoft Corporation, Washington, DC, USA) and validated
through testing on a random sample of 10 documents to ensure its clarity and efficacy in
extracting relevant data for the study. No adjustments were deemed necessary following
subsequent discussion meetings. For each included study, the following data points were
extracted: year of publication, authors, journal name, title, country, study type, participants
or number of documents included (depending on whether it was a primary study or a
review study), objectives, as well as elements pertinent to and supporting the concept of
interest and addressing the established research questions.
Data extraction was a collaborative effort, independently and blindly conducted by
two reviewers. To enhance the efficiency of data extraction and familiarization with the
extraction tool, a random sample of three articles was selected for preliminary extraction
by all authors. This was followed by an analysis and collaborative meeting to standardize
criteria, ensuring that reviewers extracted relevant data from the retained documents in
accordance with the review’s objectives.

2.7. Data Synthesis and Reporting

A third reviewer consolidated the data independently extracted by other reviewers
into a unified document, presented descriptively with supporting tables. Textual data
underwent content analysis using an inductive approach, leading to the development
of a coding structure for classifying, categorizing, and thematically grouping the data
based on similarities and thematic connections. This structured analysis facilitated a clear
understanding of the emerging themes relevant to the research questions.
 A third reviewer consolidated the data independently extracted by other reviewers
into a unified document, presented descriptively with supporting figures and tables. Tex-
tual data underwent content analysis using an inductive approach, leading to the devel-
opment of a coding structure for classifying, categorizing, and thematically grouping the
Nurs. Rep. 2024, 14 data based on similarities and thematic connections. This structured analysis facilitated a
1558
clear understanding of the emerging themes relevant to the research questions.

3. Results
3. Results
3.1.
3.1. Characterisation
Characterisation ofof the
the Reported
Reported Studies
Studies
The database search identified
The database search identified 547 547references.
references. After
After screening
screening andand selecting
selecting the the rec-
records,
ords, it was decided to include 16 articles in the review. The flowchart in Figure
it was decided to include 16 articles in the review. The flowchart in Figure 1 illustrates the1 illus-
trates the total
total number of number
identifiedofrecords,
identified records,
along along
with the with and
included the excluded
included reports,
and excluded re-
indicating
ports, indicating
the reasons the reasons
for exclusion andfor
theexclusion
documentsandincluded
the documents included
after manual after manual
examination ex-
of the
amination of the reference lists.
reference lists.

Figure
Figure 1.
1. Flowchart
Flowchart representing
representing the
the process
process of
of identifying,
identifying, screening,
screening, and
and selecting
selecting the
the references
references
included in the scoping review.
included in the scoping review.

The publication trend showed

showed a notable peak in 2020 with four studies, reflecting
heightened interest in the topic. This was followed
followed by 2017, with three studies, and 2012
and 2018, with two publications each. The The remaining
remaining years
years saw
saw aa single
single publication
publication each,
each,
suggesting a steady but less pronounced interest over time.
The studies were carried out in different
different countries, with three publications in the
StatesofofAmerica,
United States America,three
three
in in Spain,
Spain, twotwo in Australia,
in Australia, andothers
and the the others in different
in different coun-
countries
tries worldwide
worldwide (Switzerland,
(Switzerland, Iran, Iran,
Brazil,Brazil, Malaysia,
Malaysia, Italy, Italy,
Egypt,Egypt,
China, China, and Nor-
and Norway).
way). Methodologically,
Methodologically, the studies
the studies encompassed
encompassed a range
a diverse diverse ofrange
designs of including
designs including
observa-
observational, time series, continuous improvement projects, exploratory,
tional, time series, continuous improvement projects, exploratory, descriptive, cross-sec- descriptive,
cross-sectional,
tional, prospective
prospective controlled,
controlled, mixed methods,
mixed methods, narrative,
narrative, and longitudinal
and longitudinal studiesstudies
(Sup-
(Supplementary
plementary MaterialsMaterials
TableTable
S4) S4)
Figure 2 shows the geographical and temporal distribution of the studies included in
this scoping
this scoping review.
review.
The data extracted from the included studies were analyzed according to four main
dimensions: types of medication errors, predisposing factors for these errors, their conse-
quences, and interventions to minimize them. These dimensions were further organized
into categories and subcategories (Table 2), which are detailed in the following sections.
 Nurs. Rep. 2024, 14, FOR PEER REVIEW 7
Nurs. Rep. 2024, 14 1559

Figure 2. Geographical and temporal distribution of the studies included in the scoping review.
Figure 2. Geographical and temporal distribution of the studies included in the scoping review.
Table 2. Dimensions, categories, and subcategories mapped, and respective studies in which they
were identified.
The data extracted from the included studies were analyzed according to four main
dimensions: types of medication errors, predisposing factors for these errors, their conse-
Dimension Category Subcategory Study
quences, and interventions to minimize them. These dimensions were further organized
Incorrect labelling [27]
into categories and subcategories (Table 2), which are detailed in the following sections.
Preparation errors Expired infusion [27,28]
Table 2. Dimensions, categories,
Dilution and subcategories mapped, and respective[29,30]
errors studies in which they
were identified.
Omission [28,29,31,32]
Dimension Category Subcategory
Non-interruption Study
[31]
Incorrect labelling Wrong frequency [27] [29,31]
Preparation
Expired infusion Incorrect dosage [27,28] [27,29,31,33–35]
errors
Dilution errors [29,30]
Incorrect speed of administration [27,29–31,35,36]
Omission [28,29,31,32]
Incorrect route [29,31]
Non-interruption [31]
Types of errors Incorrect medication [31,37]
Wrongerrors
Administration frequency [29,31]
Drug incompatibility [27,29,35]
Incorrect dosage [27,29,31,33–35]
Types of Timetable error [29,33,38]
Incorrect speed of administration [27,29–31,35,36]
errors Non-authorised/prescribed administration [32]
Administration Incorrect route [29,31]
errors Incorrect medicationDouble administration [31,37] [39]
Drug incompatibilityNon-aseptic technique [27,29,35] [28,36]
Timetable error Interruption during administration [29,33,38] [40]
Non-authorised/prescribed
Inadequateadministration
handling of the therapeutic[32]
form [30,35]
Double administration
Transcription failures [39] [29–31]
Documentation errors
Non-aseptic technique
Lack of validation [28,36] [27,28]
Nurs. Rep. 2024, 14 1560

Table 2. Cont.

Dimension Category Subcategory Study

Work overload [27,29,34,37,40,41]
Night time [37,38,40]
Organisational constraints Low number of nurses [38]
Information overload [32]
Time constraints/Time pressure [27,32,33]
Lack of knowledge [27,29,32,33,37]
Knowledge and training Level of training [34]
Length of professional experience [34,37]
Factors predisposing to
error Inadequate physical environment [33,38,41]
System-related factors Lack of rules regulating documentation [31]
Lack of system feedback [27,32]
Fatigue [33]
Personal factors Distraction [28,29,40]
Poor relations with the work environment [29]
Manual preparation of drugs [36]
Procedure-related factors
Transcription faults [30,31]
Posting of posters [34,36,39,42]
Distribution of pamphlets/information leaflets [32,34,42]
Training/sensitization sessions [27,32,34]
Feedback sessions [27]
Discussion groups [27,39]
Educational intervention
Online drug safety resources [27,32]
Frequent training/simulation training/practical
[28,34,39]
training
Educational videos [36]
Memory aids [36]
PowerPoint presentations [36]
Creation of multifunctional forms [31]
Use of drug administration checklists [32]
Error mitigation
interventions Checking laboratory values before administration [32]
Contacting the prescriber if in doubt [32]
Verification and safety methods Monitoring vital signs before and after drug
[34]
administration
Reducing the frequency of interruptions [28]
Use of protocols [34,35,39]
Double-checking drug preparation [38]
Different colors, designs, and labels to identify
[37]
different drug recipients
Organisational and functional
Storing medicines with similar labels in different
changes [37]
places
Use of drug administration [37]
Implementation of an error reporting system [27,34]
Error reporting Reporting of medication-related events [41]
Error communication [29]
Nurs. Rep. 2024, 14 1561

3.2. Types of Errors

In the analysis of medication errors, three primary categories were identified: prepara-
tion error, administration error, and documentation error.
Errors in medication preparation included incorrect labeling [27], expired infusions [27,28],
and dilution errors [29,30].
The medication administration errors identified were: error of omission, in which the
medication is prescribed but not administered [28,29,31,32]; non-interruption of medica-
tion, in which the medication is administered although the order to interrupt is given [31];
incorrect speed/time of administration [27,29–31,35,36]; drug incompatibility [27,29,35];
unauthorized/prescribed administration [32]; duplicate administration of the drug [39];
non-aseptic technique, such as not frictioning the connection door [28,36]; interruptions dur-
ing administration [40]; errors in the handling of the pharmaceutical form to enable admin-
istration, such as crushing pills [30,35]; wrong frequency [29,31]; incorrect dosage/missed
doses [27,29,31,33–35]; incorrect route of administration [29,31]; scheduling error [29,33,38];
and wrong medication [31,37].
The documentation errors associated with nurses’ actions identified were transcription
errors between the prescription and the administration plan, namely the use of abbre-
viations, lack of dose, route of administration and schedule [29–31]; and lack of valida-
tion/incorrect recording of medication administration [27,28].

3.3. Factors Predisposing to Error

Five categories were identified regarding the factors that potentially influence nurses’
occurrence of medication errors: organizational factors, knowledge and training, system-
related factors, personal factors, and procedure-related factors.

3.3.1. Organizational Factors

Workload factors such as work overload [27,29,34,37,40,41], particularly during night
shifts [37,38,40], and a reduced number of nursing staff [38] have been identified as con-
ditions linked to the occurrence of medication errors. A lower staffing level not only
complicates the implementation of improvement interventions but also degrades the stan-
dard of care. This necessitates adaptations to the workload, forcing priorities to be altered
and some interventions to be favored over others [11].
Additionally, information overload [32] and time constraints or pressure [27,32,33] are
significant factors that contribute to medication administration errors [32]. These conditions
also pose challenges to the effective implementation of strategies aimed at improving the
medication administration process [27].

3.3.2. Knowledge and Training

Medication errors are often linked to a lack of knowledge in adhering to the five
“rights” of medication [27,33]. A misperception of error risk highlights a deficit in under-
standing the medication-related factors that can lead to mistakes [32]. In particular, nurses’
limited familiarity with the medications most commonly used in ICU settings contributes
to a higher rate of errors [29].
Additionally, a relationship has been observed between the length of professional
experience and the frequency of medication errors. Findings indicate that nurses with
more years of experience tend to demonstrate safer practices and are less prone to errors,
compared to those with less experience or recent graduation [34,37]. Surprisingly, nurses
holding a university degree were found more likely to engage in incorrect medication
management behaviors than those without a degree [34].

3.3.3. System-Related Factors

Issues such as an inadequate physical environment [33] and various system deficien-
cies in tasks and processes contribute to medication errors [41]. Furthermore, ambiguous
documentation rules result in varying interpretations by nurses, leading to inconsistent
Nurs. Rep. 2024, 14 1562

information in the administration plans [31]. The lack of systematic feedback on poten-
tial error-inducing factors leaves professionals unaware of crucial points for improve-
ment [27,32]. Effective feedback mechanisms, like those derived from a well-implemented
reporting system, are essential for identifying and resolving system flaws [27].

3.3.4. Personal Factors

Personal factors significantly affect the reliability of the drug safety process. Fa-
tigue [33], distractions, and interruptions during critical tasks such as transcription or
administration can lead to errors [28,29,40]. Poor interpersonal relationships within the
work environment also contribute to these issues [36]. Minimizing interruptions, while
considering the relevance of the interrupted information, is crucial for reducing errors [28].

3.3.5. Factors Related to Procedures

Certain nursing procedures, like the manual preparation of infusions, often result in
concentrations that deviate from those intended [36]. Transcription errors due to ambiguous
instructions, unclear dosages, or omitted administration details also lead to significant
mistakes [30,31].

3.4. Consequences of Error

Medication errors range from causing no harm to resulting in patient incapacity or even
death [28,33,34]. These errors not only harm patients but also incur substantial costs due to
increased adverse events and prolonged hospital stays [32,41]. Even non-critical errors can
escalate care levels, necessitating further tests or specialist referrals, potentially leading to a
permanent reduction in patient functional capacity and extended hospitalization [28,30,32].

3.5. Error Mitigation Interventions

Despite initial plans, the literature review did not categorize interventions by error
type due to the studies’ organizational limitations. Instead, four broad categories of
interventions were recognized: educational, verification and safety methods, organizational
and functional modifications, and error reporting.

3.5.1. Educational Intervention

The use of posters in strategic places where nurses work [34,36,39,42] is an educational
and informative strategy, and nurses are encouraged to read and consult the posters during
the preparation and administration of intravenous drugs [42].
The posters can be constructed in table form, with each line containing information on
the preparation and administration of each commonly used medication [42], but also in the
format of quick guides, step-by-step instructions explaining the procedures [39].
The distribution of pamphlets or information leaflets [32,34,42] is essential to educate
nurses about the importance of checking the expiry dates of medicines, disinfecting hands
before preparing medicines and inspecting clarity solutions [42]. The memory aids were
developed in the size of a marker, containing a preparation and administration guide
for medicines and calculation tips to serve as a quick reference, and distributed to all
nurses [36].
Training and awareness sessions [27,32,34] are an intervention used to promote med-
ication safety. They are usually presented by a qualified professional and held at a time
set aside for staff on duty, where specific medicines, topics related to the administration of
medicines, and available resources on medicines are covered [27]. Feedback sessions [27,34],
in turn, allow for a review of reported medication errors and possible solutions [28], as
well as raising awareness of errors and clinical risk management [34].
Discussion groups [27,39] about medication process safety can be held at staff meetings
with the involvement of the multidisciplinary team, and between 5 and 10 min can be set
aside for this purpose [27]. In addition, discussions can be considered during the daily staff
sessions at the beginning of each shift [39].
Nurs. Rep. 2024, 14 1563

Online resources [27,32] should be made available as a training and information-

gathering strategy, and dissemination and training on their use should be considered,
whether for checking drug compatibility [27] or for obtaining any other information about
drugs [32].
The use of medication error prevention measures also includes training in simulated
practice [28,34,39], such as the preparation and administration of intravenous medication
to a mannequin patient [28].
Educational videos [36] can be used as a complement to other educational intervention
measures, such as memory aids and the use of PowerPoint presentations, to enhance
training moments [36]. Educational videos to minimize medication error can contain a
practical demonstration of the drug preparation and administration processes, information
about general guidelines on reconstitution/dilution, drug compatibilities, administration
rates, aseptic technique, and other relevant practices [36].

3.5.2. Verification and Security Methods

To streamline the medication process and reduce transcription errors, multifunctional
forms have been developed [31]. These forms combine the prescription note and admin-
istration plan into a single document, which includes comprehensive details for each
medication such as prescription, preparation, administration, and a section to note any
discontinued medications. This integration facilitates clear communication and reduces
errors related to medication continuity [31].
Standardized operating procedures serve as effective medication error prevention
measures [34,35,39]. Protocols provide detailed instructions on the correct use of medica-
tions and are supported by the best available scientific evidence, ensuring reliability and
promoting consistent practices across healthcare settings [35].
Checklists are used to verify each step in the medication administration process,
enhancing safety and minimizing errors [32]. This strategy is complemented by routine
checks of laboratory values before administering medications, especially intravenous ones,
and by monitoring patients’ vital signs before and after administration [32,34]. Nurses are
also encouraged to contact prescribers if there are any doubts regarding the medication
orders [32,38].
Minimizing disruptions during medication preparation and administration is crucial
for reducing errors [28,38]. It is important to evaluate the necessity of interruptions,
ensuring that only essential communications occur during critical tasks.
Strategies like double-checking preparations by two nurses—one preparing and an-
other verifying—help reinforce this practice and maintain workflow coordination [38].
Implementing a double-check system, where one nurse prepares all medications for a shift
and another independently verifies them, significantly reduces the risk of errors. This
practice not only ensures accuracy but also builds a safety culture focused on collaboration
and meticulous verification [38].

3.5.3. Organizational and Functional Changes

Using strategies that involve modifying organizational and functional aspects, such
as using a different color system, designs, and labels that make it possible to identify the
different medication boxes, results in efficient measures to reduce errors [37]. In addition,
separating similarly labeled medicines in different locations is also an effective measure
for reducing medication errors [37]. The involvement of new technologies in the care
process has been pointed out as a possible error prevention measure, for example, the use
of medication administration technologies, such as the use of bar-coded medication and the
use of an electronic documentation system rather than paper documentation systems [37].

3.5.4. Error Notification

A robust incident reporting system is vital for evaluating and improving medication
safety processes [27,34,41]. Error reporting is necessary for improving the service and
Nurs. Rep. 2024, 14 1564

reducing errors [34]. In addition, medication errors should be reported to the physician
and pharmacy service, as well as to team members and supervisors, so that measures can
be taken to prevent complications [29].
Promoting a culture that views error reporting as a tool for improvement rather than
punishment is essential for identifying systemic issues and enhancing overall safety [27].
To help the error reporting process, a computer is needed in each patient unit; time is
needed for reporting; a more efficient reporting method is created; an anonymous and
depersonalized system is prioritized; greater awareness among nurses that error reporting
is intended to identify points for improvement and system errors and not personal faults;
greater awareness of the importance of the results of reporting; more training on the incident
reporting system; and ensuring that reporting is not a punishment, but an improvement
strategy [27].
The reports of medication-related events that emerge from the reporting of errors can
be relevant tools to use in feedback sessions to mitigate future events. They provide a solid
source of information about possible gaps in the safety of the medication management
process and can offer opportunities for improving the system [41].

4. Discussion
The findings of this review were categorized into four key dimensions: types of
errors, predisposing factors for errors, consequences of errors, and interventions to mitigate
medication errors. These dimensions provided comprehensive answers to the initial
research questions and objectives of this literature review.
While all included studies mentioned types of medication errors, only six explicitly
addressed the consequences of these errors [28,30,32–34,41]. Medication management
is inherently complex and error-prone, particularly during the prescription, verification,
preparation, administration, and monitoring phases [6]. Notably, the majority of impactful
medication errors occur during the preparation and administration phases—key areas of
nursing practice [3,43]. It is crucial that nurses engage in thorough analyses of errors in
these phases to enhance medication safety.
Medication errors stem from a blend of individual, organizational, task-related, work,
and team factors [44]. These errors are often procedural, arising from activities such as the
transcription process [30,31] and manual medication preparation [36]. The predominant
predisposing factors identified include work overload and a lack of knowledge, which are
intricately linked with broader health service management issues [3].
While personal factors such as knowledge, attitude, and behavior are critical, insti-
tutional factors such as staffing levels, workload, shift patterns, and physical working
conditions are major contributors to medication errors [45–47]. This aligns with findings
from this review, emphasizing that systemic issues are significant drivers of errors.
The relationship between a nurse’s education level and medication errors is com-
plex. Higher education levels have been associated with both an increase and a decrease
in medication errors [34,48,49], suggesting variability in how education impacts error
rates. However, more consistent findings indicate that increased professional experience
correlates with fewer errors [34,37]. This highlights the value of practical experience in
enhancing medication safety, where practical experience seems to play a more significant
role in reducing medication errors than formal education alone.
Interventions identified in this review include educational programs, training, double-
check systems, procedure standardization, and the use of advanced technology such as
barcode medication labeling [47,50]. Creating a culture where error reporting is encouraged
and non-punitive can lead to significant improvements in safety practices [3,45,51].
Efforts to mitigate medication errors should focus on alleviating known risk factors as
much as possible. Strategies should include educational enhancements, system corrections,
and fostering a reporting culture that encourages the communication of all error types, not
just the most severe [51]. The introduction of transformational leadership could further
improve supervision and cultivate a safety-oriented culture [52].
Nurs. Rep. 2024, 14 1565

Developing strategies based on error reports can help identify the causes of errors and
improve medication safety. The challenge remains, however, to overcome the culture of
underreporting due to fear, guilt, and the stigma of punishment [2,11,47,53,54].
The results from the included studies support a comprehensive approach to improv-
ing medication safety, focusing on education, communication, and leadership strategies.
Nursing managers are tasked with identifying system flaws and developing plans that
minimize errors and optimize outcomes in intensive care settings.

4.1. Implications for Nursing Practice

Understanding the factors that contribute to medication errors underscores the need
for multifaceted improvement interventions at various levels, including system design,
organizational structure, clinical practices, and working conditions. The high-stakes envi-
ronment of an ICU demands targeted attention to effectively mitigate medication errors
made by nurses.
The results obtained from this review study could influence the implementation of
strategies that enhance safety and reduce medication errors in intensive care settings. The
diversity of the studies reviewed provides a robust foundation for managers and nursing
professionals to enhance the efficiency of care delivery, ensuring it is safe, responsible, and
ethically sound. Additionally, these insights support organizations in improving working
conditions to achieve excellence in patient care.
While the optimal interventions for error prevention are not infallible, managers must
strategically navigate resource constraints and prioritize interventions that are collectively
beneficial and supported by strong evidence, tailored to specific contexts.
The implementation of robust error reporting tools is crucial. These tools assist
nursing managers in identifying systemic weaknesses, facilitating the development of
comprehensive personal and professional growth plans for their teams. It is essential for
healthcare professionals to recognize the importance of reporting adverse events, including
medication errors. Such reporting is critical to fostering a safety culture that prioritizes
minimizing harm, learning from incidents, and continually improving care quality.

4.2. Limitations
This literature review acknowledges several limitations that warrant consideration
and analysis. One notable limitation is the restriction on the publication timeframe of the
included studies, spanning from January 2012 to April 2023. This range was chosen because
it encompassed a period with a high concentration of relevant articles, reflecting more
contemporary professional contexts and practices. While this focus on recent literature
helps ensure the applicability of findings to current settings, it also means that valuable
insights from earlier studies may have been omitted, potentially limiting the breadth of
evidence reviewed.
Additionally, the methodological quality of the included studies was not assessed,
a decision not typically required for this type of review but one that could influence the
depth and reliability of the findings. This choice was made to avoid excluding potentially
relevant studies that, despite methodological limitations, could offer valuable insights into
the topic. This approach was intended to maximize the contribution of each study to the
comprehensive mapping of factors and interventions related to medication errors by nurses
in ICUs.
Another limitation is the exclusive focus on studies conducted in ICUs. This specificity
may overlook relevant data from other healthcare settings, such as medical-surgical units,
where different mitigation strategies might have been identified. Although these findings
could be applicable to the ICU context, their transferability is not guaranteed.
The categorization of data into defined categories and subcategories was based on the
reviewers’ interpretations and expertise, which, although validated by experts, could be
viewed as subjective. Different researchers could have categorized and interpreted the data
differently, which is a recognized limitation of this review.
Nurs. Rep. 2024, 14 1566

From the point of view of the conclusions to be drawn, it is recognized that it is

impossible to generalize widely from a geographical point of view. For example, there is
an urgent need to promote a multicenter, transnational study, including several countries
from different regions, to obtain a broad characterization of the problem.
Despite these limitations, the findings of this review are considered valuable within
the context of the study type and its objectives. The limitations do not detract from the
study’s contributions to understanding and addressing medication errors in intensive
care settings.

5. Conclusions
We believe that the results of this review study have helped to overcome the limitations
identified in previous studies on the same topic, particularly in terms of the inconsistency
of the research design and methods, fundamentally due to the methodological choice made,
i.e., the use of a scoping review, making it possible to scan the evidence published on the
topic without the restrictions imposed by other methodological approaches in terms of the
design of primary studies.
This review has elucidated a variety of errors stemming from nursing practices and
identified a comprehensive set of factors and interventions aimed at minimizing medication
errors in ICUs. These include organizational aspects, knowledge and training needs, system-
related issues, procedural dynamics, and personal factors, all of which are consistent with
the existing literature. The interventions identified, such as educational programs, safety
checks, organizational modifications, and robust error reporting mechanisms, align well
with the findings of this review.
Despite existing programs designed to reduce medication errors, the persistence of
these errors highlights an ongoing challenge. This underlines the necessity for continued
research in this vital area of nursing practice. Future studies should focus not only on
testing and refining strategies to minimize medication errors but also on exploring the
causal relationships between different types of errors and their impacts.
The significance of continuous monitoring, regular audits, and the promotion of
non-punitive error reporting cannot be underestimated. These practices are essential for
analyzing contributory factors to errors and for improving the overall conditions within
healthcare systems.
There is a critical need to enhance health service quality through strategic manage-
ment changes and appropriate organizational reforms. Moderating the nursing workload,
reducing non-essential nursing activities, boosting professional motivation, and enhancing
nurses’ knowledge and working conditions are imperative.
Understanding the factors that contribute to medication errors in intensive care settings
is crucial for developing effective mitigation strategies. This knowledge not only aids in
providing excellent healthcare but also helps in fostering a robust culture of safety.

Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/nursrep14030117/s1, Table S1: Preferred Reporting Items for Systematic
Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) Checklist; Table S2: Abstract reporting
checklist required from the PRISMA-ScR; Table S3: Search strategy conducted in the PubMed, CINAHL
(via EBSCO) and MEDLINE (via EBSCO) databases, on 8 March 2023; Table S4: Overview of the
characteristics of the studies included in the scoping review.
Author Contributions: Conceptualization, F.C. and L.F.; methodology, F.C. and L.F.; validation, F.C.,
L.F. and J.P.S.; formal analysis, F.C., L.F. and J.P.S.; investigation, F.C., L.F., N.M., H.S., H.D., C.C., C.S.
and J.P.S.; resources, F.C., L.F., N.M., H.S., H.D., C.C., C.S. and J.P.S.; data curation F.C., L.F., N.M.,
H.S., H.D., C.C., C.S. and J.P.S.; writing—original draft preparation, F.C. and L.F.; writing—review
and editing, F.C., L.F., N.M., H.S., H.D., C.C., C.S. and J.P.S.; visualization, F.C., L.F., N.M., H.S., H.D.,
C.C., C.S. and J.P.S.; supervision, J.P.S.; project administration, F.C. All authors have read and agreed
to the published version of the manuscript.
Funding: This research received no external funding.
Nurs. Rep. 2024, 14 1567

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Public Involvement Statement: No public involvement in any aspect of this research.
Guidelines and Standards Statement: This manuscript was drafted against the PRISMA-ScR (Tricco
AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L,
Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C,
Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp
Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.
Ann Intern Med. 2018. PMID: 30178033) for scoping review research.
Use of Artificial Intelligence: DeepL (DeepL SE, Colonia, Germany) was used to help translate
into English. Grammarly (Grammarly, Inc., San Francisco, CA, USA) was used to check grammar
and spelling.
Conflicts of Interest: The authors declare no conflicts of interest.

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