Medication errors as elements of patient safety: contributing factors and prevention strategies by the nursing professional

Authors

DOI:

https://doi.org/10.53732/rccsalud/2024.e6148

Keywords:

evidence-based nursing, patient safety , medication errors medication errors, nursing, patient safety

Abstract

Introduction. Medication errors (ME) can be associated with professional practice in prescribing, dispensing, distributing, administering medications, monitoring and communication problems between health professionals; The preparation and administration of medications is a highly complex process in which nursing professionals play a fundamental role as the last line of defense to prevent possible drug-related harm to the patient. The nursing professional is called upon to lead the medication administration process, assuming an essential role in the nursing team. Objective. To identify the main contributing factors and strategies for prevention, approach and management of nursing services in the face of medication errors from the perspective of patient safety. Methods: A Scoping Review type literature search was conducted in Pubmed, EBSCO host, and Science Direct. Descriptors identified in Desc and Mesh articles were used; the PRISMA methodology for reviews was used to select the articles for this article. Results: 369 articles were found in the databases addressed according to the determined criteria; 43 articles were selected for the research. Conclusion. The different elements that make up the presence of medication errors were identified; in turn, the generating and/or contributing factors for the presence of these errors during the administration of medications, in turn, strategies for prevention, approach and management of nursing services that reduce the potential risks identified were determined.

References

Martínez Rojas SP, Ibatá Bernal LM, Taborda Restrepo A, Ariza JG, Bonilla Arteaga K, Martínez Rojas SP, et al. Premezclados como alternativa para el uso seguro de medicamentos intravenosos en escenarios de atención en salud. Rev. colomb. cienc. quim. farm. 2022;51(3):1065-82. http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0034-74182022000301065&lng=en&nrm=iso&tlng=es

Figuereido Manzo B, Barbosa Brasil CL, Thibau Reis FF, Correa A dos R, Simão DA da S, Costa ACL. Seguridad en la administración de medicamentos: investigación sobre la práctica de enfermería y circunstancias de errores. Enferm. glob. 2019;18(56):19-56. http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412019000400002&lng=es&nrm=iso&tlng=es

Puma-Quito RS, Mesa-Cano IC, Ramírez-Coronel AA, Pacurucu-Avila NJ. Efectividad de intervenciones de enfermería basada en protocolos de administración segura de medicamentos por vía venosa: revisión sistemática. Archivos Venezolanos de Farmacología y Terapéutica. 2021;40(3):266-74. https://doi.org/10.5281/zenodo.5039444

Rodríguez Vinueza VI, Sánchez Morales RV, Quispillo Moyota JM, Rincón Alarcón AC. Identificación de errores de medicación en pacientes con enfermedades crónicas no transmisibles en un hospital de Tungurahua, Ecuador. An Real Acad Farm. 2019;85(2):182-8. https://analesranf.com/articulo/8502_art02/

Adsuar-Meseguer GM, Santos-Cruz P, Pérez-Rodríguez RO, Granados-Flores J, Grande de Ulierte E, López Alarcón MD, et al. Strategy to optimize patient safety in the community pharmacy dispensing service. Proposed checklists. Farm comunitarios. 2023;15(2):29-40. https://doi.org/10.33620/FC.2173-9218.(2023).15

Alves Dos Santos PR, Rossi Rocha FL, Sampaio CSJC. Actions for safety in the prescription, use and administration of medications in emergency care units. Rev Gaucha Enferm. 2019;40(spe); e20180347. https://doi.org/10.1590/1983-1447.2019.20180347

Torres Y, Rodriguez Y, Perez E. Procedimiento para el análisis y la prevención de errores de medicación usando el enfoque de la ergonomía. Rev. Fac. Nac. Salud Pública. 2022;40(2):e346223-e346223. https://revistas.udea.edu.co/index.php/fnsp/article/view/346223/20811613

Burguet-Lago N, Campaña Burquet A, Troche Concepción Y. Heparina sódica 5000 UI/mL, detección de eventos adversos relacionados con errores de medicación: notificaciones espontaneas. Rev. CENIC Cienc. Biol. 2022; 53(2):2221-450. http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S2221-24502022000200160

Lee H. A meta-analysis of the effects of intervention on the prevention of medication administration errors in nurses. Medico-Legal Update. 2019;19(1):659-66. https://doi.org/10.5958/0974-1283.2019.00117.8

de Azevedo Filho M, Martins S, Silva Soares R, Fazendeiro G, de Brito Paranaguá T, Bezerra Q. Administración de medicamentos: conocimiento de los enfermeros del sector de urgencia y emergencia. Enferm. glob. 2012; 12(26). https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412012000200005

Berrío Valencia MI. Prevención de errores en la administración de medicamentos en anestesia. CES Medicina. 2014;28(2):307-12. http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-87052014000200015&lng=en&nrm=iso&tlng=es

Manias E, Street M, Lowe G, Low JK, Gray K, Botti M. Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Serv Res. 2021;21(1):1025. https://doi.org/10.1186/s12913-021-07033-8

Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1). https://doi.org/10.1186/s12874-018-0611-x

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73. https://pubmed.ncbi.nlm.nih.gov/30178033/

Park J, Han AY. Medication safety education in nursing research: Text network analysis and topic modeling. Nurse Educ Today. 2023;121. https://doi.org/10.1016/j.nedt.2022.105674

Chávez-Jiménez L. Errores de administración de medicamentos en enfermería. Rev enferm neurol. 2021;20(1):58-65. https://revenferneurolenlinea.org.mx/index.php/enfermeria/article/view/333/359

Rodríguez Vinueza VI, Vinicio Sánchez Morales R, Quispillo Moyota JM, Rincón Alarcón AC. Identificación de errores de medicación en pacientes con enfermedades crónicas no transmisibles en un hospital de Tungurahua, Ecuador. An Real Acad Farm, 2019;85(2):182-188. https://dialnet.unirioja.es/servlet/articulo?codigo=7038270&info=resumen&idioma=ENG

Bohórquez-Moreno C, Manotas-Castellar M, Ríos-Paternina A, Hernández-Bello L, Bohórquez-Moreno C, Manotas-Castellar M, et al. Errores de medicación en pacientes hospitalizados: una revisión sistemática. Ars Pharmaceutica. 2021;62(2):203-18. https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S2340-98942021000200203&lng=es&nrm=iso&tlng=es

Figueiredo Manzo B, Barboza Brasil CLG, Thibau Reis FF, Reis Correa A, da silva DA, Leite Costa AC. Seguridad en la administración de medicamentos: investigación sobre la práctica de enfermería y circunstancias de errores. Enferm. glob. 2019;18(56):19-56. http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412019000400002&lng=es&nrm=iso&tlng=es

Mardani A, Griffiths P, Vaismoradi M. The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review. J Multidiscip Healthc. 2020;13:1347-61. https://doi.org/10.2147/JMDH.S276061

Martínez Betancourth A. Errores, factores influyentes y estrategias de prevención frente a la administración de medicamentos [Tesis de Grado]. Colombia. Universidad de Ciencias Aplicadas y Ambientales. 2018. https://repository.udca.edu.co/server/api/core/bitstreams/8a64f2e9-ebb5-4609-ade2-2452b2fa65f3/content

Domínguez Martínez MY, Pérez Castro y Vázquez JA, Soto Arreola M. Eficacia de la práctica de enfermería en la administración de medicamentos. Revista CONAMED. 2015;20(S1):S35-40. https://dialnet.unirioja.es/servlet/articulo?codigo=7292892

Lee H. A meta-analysis of the effects of intervention on the prevention of medication administration errors in nurses. Medico-Legal Update. 2019;19(1):659-66. https://www.semanticscholar.org/paper/A-Meta-Analysis-of-the-Effects-of-Intervention-on-Lee/5745e021cd9012d4be9bdbc8c065e5988920e309

Barberán J, Barberán LC, de la Cuerda A. Safety in the selection of oral antibiotic treatment in community infections, beyond COVID-19. Rev Esp Quimioter. 2021;34(4):289-97. https://doi.org/10.37201/req/087.2021

Caro Ríos S, Díaz Agudelo D, De las Salas Martínez R, Gutiérrez Cantillo E, Lemus Jiménez C, Quintero Meléndez S. Conocimientos relacionados con aspectos de la administración de medicamentos en la práctica de enfermería en tres hospitales del Atlántico (Colombia). Revista Científica Salud Uninorte. 2014;30(3):371-80. http://dx.doi.org/10.14482/sun.30.3.6003

Wernli U, Hischier D, Meier CR, Jean-Petit-Matile S, Kobleder A, Meyer-Massetti C. Pharmacists’ clinical roles and activities in inpatient hospice and palliative care: a scoping review. Int J Clin Pharm. 2023;45(3):577-86. https://doi.org/10.1007/s11096-023-01535-7

Manias E, Bucknall T, Hughes C, Jorm C, Woodward-Kron R. Family involvement in managing medications of older patients across transitions of care: a systematic review. BMC Geriatr 2019;19(95). https://doi.org/10.1186/s12877-019-1102-6

Wernli U, Dürr F, Jean-Petit-Matile S, Kobleder A, Meyer-Massetti C. Subcutaneous Drugs and Off-label Use in Hospice and Palliative Care: A Scoping Review. J Pain Symptom Manage.2022;64(5):e250-9. https://doi.org/10.1016/j.jpainsymman.2022.07.006

Hermanns H, Bos EME, van Zuylen ML, Hollmann MW, Stevens MF. The Options for Neuraxial Drug Administration. CNS Drugs. 2022;36(8):877-96. https://doi.org/10.1007/s40263-022-00936-y

Santi T, Beck CLC, da Silva RM, Zeitoune RG, Tonel JZ, do Reis DAM et al. Error de medicación en un hospital universitario: percepción y factores relacionados. Enferm. glob. 2014;13(35):160-71. https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412014000300010&lng=es&nrm=iso&tlng=es

Castro Gonzalez LV, Martinez Contreras AM, Caro VJ, Barreras Serrano A, Dautt Silva J. Medication errors in hospitalized patients in the Internal Medicine service. Med Int Mex. 2020;36(6):751-8. https://doi.org/10.24245/mim.v36i6.3410

Coben D, Weeks K. Meeting the mathematical demands of the safety-critical workplace: Medication dosage calculation problem-solving for nursing. Educ Stud Math. 2014;86(2):253-70. https://doi.org/10.1007/s10649-014-9537-3

Kvarnström K, Niittynen I, Kallio S, Lindén-Lahti C, Airaksinen M, Schepel L. Developing an In-House Comprehensive Medication Review Training Program for Clinical Pharmacists in a Finnish Hospital Pharmacy. Int J Environ Res Public Health. 2023;20(12):6158. https://doi.org/10.3390/ijerph20126158

Jiang N, Sun MM, Zhou YY, Feng XX, Feng MBBS XX. Significance of Patient Participation in Nursing Care. Altern Ther Health Med. 2021;27(5):115-9. https://pubmed.ncbi.nlm.nih.gov/32857729/

Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf. 2020;11. https://doi.org/10.1177/2042098620968309

Dupoiron D, Duarte R, Carvajal G, Aubrun F, Eldabe S. Rationale and Recent Advances in Targeted Drug Delivery for Cancer Pain: Is It Time to Change the Paradigm?. Pain Psysician. 2022;25:e415-425. https://livrepository.liverpool.ac.uk/3156779/1/2022%3B25%3BE414-E425.pdf

Mohammady M, Radmehr M, Janani L. Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database Syst Rev. 2021;6(6):CD00807. https://doi.org/10.1002/14651858.CD008077.pub6

Sepúlveda Armendáriz JA. Prevención de errores de medicación. Metas enferm. 2010;13(4):26-31. https://pesquisa.bvsalud.org/portal/resource/pt/ibc-85732

Luetsch K, Rowett D, Twigg MJ. A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why? BMJ Qual Saf. 2020;30(5):418-30. https://doi.org/10.1136/bmjqs-2020-011418

Müller M, Jürgens J, Redaèlli M, Klingberg K, Hautz WE, Stock S. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. https://doi.org/10.1136/bmjopen-2018-022202

Vinette B, Côté J, El-Akhras A, Mrad H, Chicoine G, Bilodeau K. Routes of administration, reasons for use, and approved indications of medical cannabis in oncology: a scoping review. BMC Cancer. 2022;22(1):319. https://doi.org/10.1186/s12885-022-09378-7

Schuster S, Singler K, Lim S, Machner M, Döbler K, Dormann H. Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department. Scand J Trauma Resusc Emerg Med. 2020;28:68. https://doi.org/10.1186/s13049-020-00756-3

Wigneswaran J, St. Peter WL, Nissenson AR, Krishnan M, Faris R, Becker B, et al. Redefining Medication Management in Dialysis: A Kidney Pharmacy Quality Pyramid. Kidney Med. 2019;1(5):307-14. https://doi.org/10.1016/j.xkme.2019.06.008

Rojas Marín MZ, Castillo Penagos CD, Orduz Diaz YD, Segura Suárez MA. Estrategias para la prevención de errores en la administración de medicamentos intravenosos. Investig. enferm. imagen y desarro. 2021;23. https://doi.org/10.11144/Javeriana.ie23.epea

Cafarotti A, Giovannini M, Begìn P, Brough HA, Arasi S. Management of IgE-mediated food allergy in the 21st century. Clin Exp Allergy. 2023;53(1):25-38. https://doi.org/10.1111/cea.14241

Broadhurst D, Cooke M, Sriram D, Gray B. Subcutaneous hydration and medications infusions (effectiveness, safety, acceptability): A systematic review of systematic reviews. PLoS One. 2020;15(8):e0237572. https://pubmed.ncbi.nlm.nih.gov/32833979/

Published

2024-09-24

How to Cite

Fonseca, Y. R., & López Castelblanco, G. (2024). Medication errors as elements of patient safety: contributing factors and prevention strategies by the nursing professional. Revista científica Ciencias De La Salud, 6, 01–14. https://doi.org/10.53732/rccsalud/2024.e6148