1 Background
2 Literature Search Method
2.1 Search Strategy
2.2 Inclusion and Exclusion Criteria
2.3 Data Extraction Method
2.4 Definitions
2.5 Data Analysis
2.5.1 Categorisation
2.5.2 Quality Assessment
3 Results
3.1 Search Process
3.2 Study Characteristics
3.2.1 Country of Origin
Key details | Country | Setting | Study duration | Patient population | Route studied |
---|---|---|---|---|---|
Hall et al. [76] | Canada | 1 × H: general medicine, general surgery, geriatrics, private | 176 h | NS | All |
Dean et al. [38] | UK and USA | 2 × H: 2 × medical-surgical wards (USA), 2 × medicine, 2 × surgery, 2 × geriatric (UK) | USA (1 month), UK (2 months) | NS | Other |
Gladstone [52] | UK | 1 × H | 12 months | NS | All |
Leape et al. [56] | USA | 2 × tertiary H 5 ICUs, 4 × non-obstetric general medical care units, 2 × non-obstetric general surgical care units | 6 months | A | All |
Baker [67] | Australia | 1 × H 9 × wards | 18 weeks (2 per ward) | NS | All |
Cavell and Hughes [48] | UK | 2 × H: 1 × medical ward per H | 77 drug rounds | NS | All |
Cullen et al. [57] | USA | 2 × H 2 × medical ICU, 3 × surgical ICU, 4 × medical general care, 2 × surgical general care units | 6 months | A | All |
Ho et al. [47] | UK | 1 × H: 1 × female geriatric ward | 16 days | A | Other |
Hartley and Dhillon [50] | UK | 1 × H: 2 × general surgical wards, 1 × general medical ward | 39 days | NS | IV |
Taxis et al. [37] | UK and Germany | 3 × H: (1 × UK, 2 × Germany) two adult wards at each site | 1 week per ward | A | Other |
Dean and Barber [46] | UK | 1 × H: 1 × medical, 1 × surgical ward | 3 months | NS | All |
Fasting and Gisvold [87] | Norway | 1 × H | 36 months | A, C | IV |
Hand and Barber [51] | UK | 1 × H Various units: general medical, general surgical, care of elderly, paediatric, neonatal, haematology, renal, obstetric/labour | NS | A, C | All |
Bruce and Wong [49] | UK | 1 × H: 1 × medical admissions ward | Approx. 170 h | NS | IV |
Orser et al. [75] | Canada | Members of the CAS | NS | NS | IV |
Webster et al. [72] | New Zealand | 2 × H | 22 months | A, C | IV |
UK | 2 × H: 10 × units, including ICU, paediatrics, surgery, cardiology, nephrology | 6–10 days per unit | A, C | IV | |
Wirtz et al. [39] | UK and Germany | 2 × H (Germany), 1 × H (UK) 2 × units per H | 12 days per H | NS | IV |
Balas et al. [54] | USA | Sample of staff nurses working in various units in Hs, who were members of ANA | 28 days | A, C | All |
Gordon [71] | South Africa | Members of the Department of Anaesthesia at the University of Cape Town | NS | NS | IV |
Manias et al. [66] | Australia | 1 × H medical and surgical units | NS | NS | All |
Germany | 1 × H 1 × ICU, 1 × surgical ward | 6–7 days per unit | A | IV | |
Deans [64] | Australia | 1 × H 3 × surgical units, 2 × medical units, 1 × palliative care facility | 4 weeks | NS | All |
Haghenbeck [61] | USA | Members of AACN | NS | A | All |
Stetina et al. [60] | USA | H | NS | A, C | All |
van Gijssel-Wiersma et al. [79] | Netherlands | 1 × H: 1 × internal medicine unit | 3 weeks | A | All |
Balas et al. [58] | USA | Sample of staff nurses working in various critical care units in Hs, who were members of the AACN | 28 days | A, C | All |
Gordon et al. [68] | South Africa | Anaesthetists on South African Society of Anaesthesiologists database | NS | NS | IV |
Kopp et al. [7] | USA | 1 × H: 1 × medical/surgical ICU | 33 × 12-h nursing shifts | A | Other |
Buckley et al. [6] | USA | 1 × H: 1 × paediatric medical/surgical ICU | 26 × 12-h nursing shifts | C | All |
McBride-Henry and Foureur [73] | New Zealand | 1 × H Nurses from various clinical units | 1 year | NS | All |
Sanghera et al. [53] | UK | 1 × H 1 × ICU | 4 months | NS | All |
Tang et al. [82] | Taiwan | National Yang-Ming University Various clinical units | NS | NS | All |
Nichols et al. [62] | Australia | 1 × H | 6 months | NS | All |
Taylor et al. [55] | USA | 1 × H: 1 × NICU | Approx. 19 months | C | Other |
Chua et al. [77] | Malaysia | 1 × H: 1 × haematology ward | 15 days | NS | All |
Llewellyn et al. [69] | South Africa | 3 × H | 6 months per hospital | NS | IV |
Chua et al. [78] | Malaysia | 1 × H Two paediatric wards (general, oncology) | 10 days per ward | C | All |
Dickinson et al. [74] | New Zealand | 1 × paediatric H All inpatient areas included | NS | C | All |
USA | 158 active nurses from the Georgia Board of Nursing | NS | NS | All | |
Rai [81] | India | 1 × H | NS | NS | IV |
Reid-Searl et al. [63] | Australia | School of Nursing and Midwifery, CQ University Australia | NS | NS | All |
Kim et al. [85] | South Korea | 4 × teaching H, 2 × private H, 1 × government H | 2 months | NS | All |
Labuschagne et al. [70] | South Africa | 22 × public sector H. All anaesthetising doctors included | NS | NS | IV |
Ozkan et al. [88] | Turkey | 1 × H 1 × paediatric ward | 1 year | C | All |
Agalu et al. [84] | Ethiopia | 1 × H 1 × ICU | 2 months | A, C | All |
Colligan and Bass [59] | USA | NS | NS | C | All |
Gill et al. [65] | Australia | 1 × paediatric H Surgical and PICU | 1 year | C | All |
Rodriguez-Gonzalez et al. [80] | Spain | 1 × H 2 × gastroenterology units | 1 week | A | All |
Vazin and Delfani [83] | Iran | 1 × H 1 × ICU | 228 h | A | All |
Zhang et al. [86] | China | 1 × H 64 operating theatres | 6 months | A, C | IV |
Key details | Subject(s) studied | Method of MAE collection | Data collection method for MAE causes | Data collector(s) ± reviewer(s) | |
---|---|---|---|---|---|
Error | Causes | ||||
Hall et al. [76] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Dean et al. [38] | Nurses | DO | DO | 2 × pharmacist observers | 2 × pharmacist observers |
Gladstone [52] | Nurses | Semi-structured interviews | Semi-structured interviews | Nurse interviewer | Nurse interviewer |
Leape et al. [56] | Ward staff involved with errors | Incident reports and chart review. Questionable cases discussed with additional investigator for consensus | Interviewing staff responsible/witnesses—physicians, nurses, pharmacists. Utilised structured data collection form | Nurse investigator | Peer case investigator |
Baker [67] | Nurses | DO, informal and formal interviews | DO, informal and formal interviews | Nurse researcher | Nurse researcher |
Cavell and Hughes [48] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Cullen et al. [57] | Unit personnel | Incident report, chart review and independent review | Structured interview | Nurse investigator, ward staff | Nurse peer case investigator |
Ho et al. [47] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Hartley and Dhillon [50] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Taxis et al. [37] | Nurses | DO | DO | 2 × pharmacist observers | 2 × pharmacist observers |
Dean and Barber [46] | Nurses | DO | DO | 2 × pharmacist observers | 2 × pharmacist observers |
Fasting and Gisvold [87] | Anaesthesiologists and nurse anaesthetists | Prospective procedure record dataset | Prospective procedure record dataset | Self-report by anaesthesiologist | Self-report by anaesthesiologist |
Hand and Barber [51] | Nurses | Semi-structured interviews | Semi-structured interviews and coding | Pharmacist interviewer | Pharmacist interviewer |
Bruce and Wong [49] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Orser et al. [75] | Anaesthesiologists | Questionnaire survey | The survey questionnaire asked respondents who had reported a wrong drug error to choose one or more factors contributing to the incident from a pre-prepared list | Anaesthesiologists self-report via survey | Anaesthesiologists self-report via survey |
Webster et al. [72] | Anaesthetists | Study form after each anaesthetic administration | Study form after each anaesthetic administration—asked for contributory factors for error | Self-report via monitoring form | Self-report via monitoring form |
Nurses and physicians | DO | DO + information conversations with ward staff | Pharmacist observer | Pharmacist observer. Data coded by both authors | |
Wirtz et al. [39] | Nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Balas et al. [54] | Nurses | 40 question per day error log book | 40 question per day error log book with narrative error descriptions | Self-report by nurses | Self-report by nurses |
Gordon [71] | Anaesthetists | Confidential self-report questionnaire survey | Questionnaire survey—section asking what factors contributed to the incident | Self-report survey questionnaire | Self-report survey questionnaire |
Manias et al. [66] | Nurses | Semi-structured interview | Semi-structured interview | Nurse researcher interviewer | Nurse researcher interviewer |
Nurses | DO | DO and informal conversations with staff | Pharmacist observer | Pharmacist observer. Data coded by both authors | |
Deans [64] | Nurses | MEQ | MEQ—contains five sections asking the nurse to identify what they thought the cause of their error(s) was | Self-reported by nurse subjects | Self-reported by nurse subjects |
Haghenbeck [61] | Nurses | Interview | Interview | Nurse researcher interviewer | Nurse researcher interviewer |
Stetina et al. [60] | Nurses | Interview | Interview | Nursing doctoral students | Nursing doctoral students |
van Gijssel-Wiersma et al. [79] | Nurses and student nurses | DO | DO | Pharmacist observer | Pharmacist observer |
Balas et al. [58] | Nurses | 41 question per day error log book | 41 question per day error log book with narrative error descriptions | Self-report by nurses | Self-report by nurses |
Gordon et al. [68] | Anaesthetists | Confidential self-reporting survey tool | Confidential self-reporting survey tool—factors contributing to medication errors identified | Anaesthetist subjects | Anaesthetist subjects |
Kopp et al. [7] | Nurses | DO followed by independent review of data | DO (and listening to nurse conversations?), followed by independent review of data | 2 pharmacists and 2 reviewers (physician and pharmacist) | 2 pharmacists and 2 reviewers (physician and pharmacist) |
Buckley et al. [6] | Nurses | DO followed by independent review of data | DO followed by independent review of data | 2 pharmacists and 2 reviewers (physician and pharmacist) | 2 pharmacists and 2 reviewers (physician and pharmacist) |
McBride-Henry and Foureur [73] | Nurses | Semi-structured focus group | Semi-structured focus group | Nurse researcher | Nurse researcher |
Sanghera et al. [53] | Nurses | Incident reports and routine pharmacist activity | Semi-structured interview asking about reasons for error(s) | Unit pharmacist and ward staff | Interviewer researcher |
Tang et al. [82] | Nurses and RN nursing students | Semi-structured questionnaire survey | Semi-structured questionnaire survey (34 possible contributory conditions under eight categories) | Nurses self-reported via survey | Nurses self-reported via survey |
Nichols et al. [62] | Nurses | Routine pharmacist activity | Staff interviewed by a researcher using both closed- and open-ended questions to determine contributory events and conditions and possible contributory factors from a list | Clinical pharmacists | Interview with researcher |
Taylor et al. [55] | Nurses | DO | DO and data review and classification | Research nurse observer | Research nurse observer and reviewers |
Chua et al. [77] | Nurses and physician | DO and discussion of cases with researchers | DO and interviews with staff involved with errors witnessed (author correspondence) | NS observer (researcher) and reviewers (pharmacist and physician) | NS observer (researcher) |
Llewellyn et al. [69] | Doctor anaesthetists (specialists and trainees) | Error reporting forms for every anaesthetic performed | Error reporting forms for every anaesthetic performed—additional details on reasons for error | Self-reported via form | Self-reported via form |
Chua et al. [78] | Nurses and physicians | DO | DO and interview with staff involved in error (author correspondence) | NS observer | NS observer |
Dickinson et al. [74] | Nurses (various grades) | Focus groups | Focus groups | Nurse researchers doing interviews | Nurse researchers doing interviews |
Nurses | Self-report survey | Self-report survey—open-ended questions about factors contributing to specific error | Nurses self-reported via questionnaire survey | Nurses self-reported | |
Rai [81] | Anaesthesiologists (incl. trainees) | Self-report anonymous questionnaire | Self-report anonymous questionnaire—no further detail given | Self-report by anaesthesiologists | Self-report by anaesthesiologists |
Reid-Searl et al. [63] | Nursing students | Semi-structured individual interviews | Semi-structured individual interviews | Nurse researcher | Nurse researcher |
Kim et al. [85] | Nurses (incl. Senior roles) | Self-report using questionnaire survey | Self-report using questionnaire survey—multiple choice contributing factors selected | Nurses self-report: questionnaire survey | Nurses self-report: questionnaire survey |
Labuschagne et al. [70] | Various grade of doctor administering anaesthesia | Self-report survey questionnaire | Self-report questionnaire survey—identify one or more factors associated with error(s) | Self-reported using questionnaire survey | Self-reported using questionnaire survey |
Ozkan et al. [88] | Nurses | DO | DO and semi-structured interview using critical incident technique | Nurse student observer | Nurse student observer and researcher (interviewer) |
Agalu et al. [84] | Nurses | DO and chart review | DO and chart review | Nurse and pharmacist data collectors | Nurse and pharmacist data collectors |
Colligan and Bass [59] | Nurses | DO, simulation exercises and semi-structured interviews | Semi-structured interviews and simulation | NS interviewer | NS interviewer |
Gill et al. [65] | Nurses | Questionnaire | Questionnaire | Self-reported by nurse participants | Self-reported by nurse Participants |
Rodriguez-Gonzalez et al. [80] | Nurses and nurse assistants | DO | Observer and two senior pharmacists, with a third investigator taking part for consensus | 6 pharmacists and 5 nurses | 6 pharmacists and 5 nurses, 2 senior pharmacists plus third investigator |
Vazin and Delfani [83] | Nurses | DO | DO | Pharmacist observers | Pharmacist observers |
Zhang et al. [86] | Anaesthetists | Study form after each anaesthetic administration | Study form after each anaesthetic administration—asked for contributory factors for error | Self-report via monitoring form | Self-report via monitoring form |