Roles and systems for routine medication administration to prevent medication errors in hospital-based, acute care settings: a systematic review.
BACKGROUND
Levels of medication administration error have been reported as accounting for 38% of all adverse drug events and have been calculated as occurring in 3-8% of all administrations. The majority of these will occur as part of "routine" administration.


OBJECTIVE
To undertake a systematic review of roles and systems for preventing medication error during routine medication administration in hospital-based acute care settings and of perceptions of causes of error.


METHODS
Types of participants- Participants were nurses, pharmacists, pharmacy technicians, medical and surgical staff and adult patients in hospital-based, acute care settings.Types of intervention/Phenomena of interest- Intervention related to administration systems and related to roles of those who administer medicines were considered. The perceptions of causes of error was the phenomena of interest.Types of outcomes- 1) Number of medication administration errors, and 2) Nurses and patients' perceptions of causes of medication errorTypes of studies- Quantitative studies of medication error rates for differing medication systems and roles of those administering medications. Qualitative and descriptive studies of perceived causes of errors.


METHODS
The review sought studies published in English from 1990 to December 2008. 23 databases, websites and search engines were searched.


METHODS
Critical appraisal tools from Joanna Briggs Institute were used. Two reviewers appraised studies independently. 35 studies out of 1004 identified papers were critically appraised. 19 studies met the inclusion criteria.


METHODS
Data were extracted using standardised extraction forms.


RESULTS
It was not possible to undertake meta-analysis due to lack of studies in all categories and lack of similarity between studies. Quantitative results were combined in a narrative summary. Qualitative studies were synthesised accordingly using a meta-aggregative approach.


RESULTS
Nurses perceptions of medication administration errors suggest that ineligible prescriptions and distractions/interruptions (external factors) are perceived as key causes of error. Limited evidence on patient perceptions, suggest that their inclusion in routine medication administration may reduce errors.Studies related to routine medication administration roles and systems are small and lack power and generalisability to all acute care contexts. What evidence exists suggests routine medication that is individualised to the patient and administered close to the bedside, reduces error.There is equivocal evidence related to differing roles of nurses. The use of dedicated medication nurses and primary administration (nurse administers "own" patient medications) are inconclusive. Equivocal evidence related to three system types was identified: self administration; trolley, bay and bedside systems; individualised and unit dose medications.There is no evidence of effectiveness related to one or two nurse checking or related to the use of devices to reduce distractions, such as signs or tabards.


CONCLUSIONS
Administration from individually labelled medication, administered close to the patient, appear to be the most significant factors in reducing errors during routine medication rounds. Nurses' perspectives on causes of medication errors, may differ from those recorded. There is no conclusive evidence that manipulating the nursing role has any impact on errors.Implication for practice- Individual or patient dose systems used with administration occurring as close to the patient as possible. Including the patient more fully in the administration process through self administration or involvement in the checking process has some potential for reducing errors.Implication for research- The review identifies the need for rigorous large scale further research.
1. The Scottish Centre for Evidence-based Multi-professional Practice: A Collaborating Centre of the Joanna Briggs Institute, The Robert Gordon University.
Peter
P
Wimpenny
Pamela
P
Kirkpatrick