Table 1 Characteristics of the included studies (n = 22)

Short (1993)

[20]/Hong Kong

Prospective observational study/1 year

To find out the cause related to anesthetic critical events

P: anesthesiologists who reported the critical events

E: 125 critical events that were reported by anesthesiologists in 16,379 anesthesia cases

A hospital (1430 beds)

D: a review of the voluntary reporting of critical events

Singleton (1993)

[21]/Australia

Retrospective study/NA

To analyze the problems associated with vascular access

P: individuals who voluntarily and anonymously reported any unintended incidents that either reduced or had the potential to reduce the safety margin for a patient

E: 65 events involving problems with access to the vascular system of the first 2000 incidents reported to the AIMS

Hospitals and other healthcare settings

D: a review of reporting to AIMS

Goldspiel (2000)

[22]/USA

Project study/54 months

To reduce the number of chemotherapy-related medication errors

P: members from the pharmacy department, nursing department, National Cancer Institute intramural program, information system department, and hospital administration

E: chemotherapy-related medication errors occurred during the study period

A hospital (325 beds)

I: PDCA (plan-do-check-act) performance improvement model with a comprehensive, interdisciplinary approach

D: prescribing errors that were detected before medication preparation and medication errors that were reported through an occurrence-reporting system

Taxis (2003)

[23]/UK

Qualitative study/76 days

To investigate the causes of IV medication errors in drug preparation and administration

P: 113 nurses and 1 doctor

E: 265 IV medication errors in 483 drug preparation and 447 drug administration

10 wards in two hospitals

D: observation by trained pharmacists

Wetterneck (2006)

[24]/USA

Project study/6 months

To describe the use of FMEA to guide the implementation of a smart IV pump

P: a multidisciplinary team which was composed of representatives from anesthesiology, biomedical engineering central supply, industrial engineering, internal medicine, nursing, pharmacy, and quality improvement

E: Failure modes expected before implementation of smart IV pump and failure modes that occurred 3 months after implementation

A hospital

I: smart IV pump implementation equipped with FMEA by a multidisciplinary committee

Rinke (2007)

[25]/USA

Retrospective study/6 years

To identify patterns in pediatric chemotherapy errors

P: healthcare professionals who voluntarily reported pediatric chemotherapy errors in the national medication safety reporting system

E: 310 pediatric chemotherapy error reports of 829,492 errors reported to internet-accessible, anonymous adverse drug reactions and medication errors reporting program

69 healthcare facilities

D: a review of the incidents reported to the reporting program database from 1999 to 2004

Nuckols (2008)

[26]/USA

Mixed methods/20,559 bed-days

To compare preventable IV ADE incidence rates between smart pumps and infusion pumps

P: 4 ~ 5 critical care nurses per hospital and 4 board-certified internal medicine physicians

E: 100 preventable IV ADE among 4604 patients

ICUs in two hospitals

D: retrospective medical chart review and qualitative descriptions of errors

Evans (2010)

[27]/USA

Project study/22.5 months

To evaluate the smart system that could detect pump programming errors

P: nurses and critical care clinical pharmacists

E: 970 alerts on 25,040 infusion pump cases

ICU (24 beds) in one hospital (456 beds)

I: a smart system that was connected to the EMR to prevent pump programming errors

D: follow-up on every pump alert by a critical care clinical pharmacist

Ligi (2010)

[28]/France

Project study/4 years

To evaluate the effect of continuous incident reporting and subsequent prevention strategies on the incidence of severe iatrogenic events and targeted priorities in admitted neonates

P: staff members (physicians, senior nurses, and nurses)

E: 622 iatrogenic events among 1033 neonates

Neonatal center (54 beds)

I: prospective, continuous incident reporting followed by the implementation of prevention strategies such as double-checks infusion pump programming by a multidisciplinary care quality improvement team

D: voluntary incident reports from the anonymous, non-punitive system

Westbrook (2011)

[40]/Australia

Prospective observational study/11 months

To explore the IV administration errors and the relationships between errors, procedural failures, and nurse experience

P: 107 nurses

E: 568 IV medication administrations

6 wards across two hospitals (400 beds, 326 beds, respectively)

D: observation by 3 researchers (registered nurses or doctors)

Kandil (2012)

[2]/Egypt

Prospective observational study/9 months

To find out the patterns of medication errors in an obstetric emergency ward

P: 10,000 patients

E: 1976 administration errors of 47,192 medical prescriptions

An obstetric emergency ward

D: observation by head nurses and retrospective review of the patients’ charts and nurses’ notes by the authors

Rodriguez-Gonzalez

(2012) [29]/Spain

Prospective observational study/1 week

To identify the frequency of medication preparation and administration errors in medical units using automated prescription and dispensing systems

P: 23 nurses and 73 patients

E: 509 errors in 2314 medication administrations

Two gastroenterology units (30 and 29 beds) in one hospital (1537 beds)

D: observation by trained pharmacists and nurses

Ohashi (2013)

[30]/USA

Project study/3 days

To develop a web-based IV medication error observational tool and validate the tool

P: 55 patients

E: 171 errors of 181 IV medication administrations observed

Medical ICU, surgical ICU, and general surgical units in one hospital (793 beds)

I: a web-based data collection tool that was developed by an interdisciplinary team

D: observation by two nurses using the Redcap

Nguyen (2014)

[37]/Vietnam

Controlled pre-posttest study/5 weeks

To evaluate the effect of the training program on clinically relevant errors during IV medication preparation and administration

P: nurses in the two ICUs

E: 1204 IV medication administration (516 during the baseline period and 688 during the follow-up period)

ICU (the intervention ward) and PSU (the control ward) in one hospital

I: clinical pharmacist-led training program that was developed by a clinical pharmacist and the chief nurse (classroom lectures, practice-based education, two posters and written guidelines for safe preparation and administration)

D: observation by nurses

Prakash (2014)

[31]/Canada

Simulation laboratory experiment study/6 months

To assess the effects of interruption on medication verification and administration errors, and the effectiveness of targeted interventions

P: 37 nurses (experimental group: 19, control group: 18)

E: errors in 385 medication verification and administration tasks (pre-intervention: 252, post-intervention: 133)

Simulated ambulatory chemotherapy setting

I: verification booth, standardized workflow, speaking aloud for medication verification tasks, visual timers for IV pushes, no interruption zones with motion-activated indicators, and reminder signage for medication administration tasks

D: observation by two trained observers in an observation room located behind a one-way glass

Bagheri-Nesami

(2015) [38]/Iran

Descriptive cross-sectional study/2 months

To identify the frequency of IV infusion errors and their causes in cardiac critical care units

P: 190 nurses

E: 262 IV medication errors

Cardiac critical care units from 12 teaching hospitals

D: self-reporting questionnaire

Schnock (2017)

[32]/USA

Prospective observational study/2 ~ 4 days

To investigate the frequency and types of IV medication errors related to smart pumps

P: 478 patients

E: 1691 errors of 1164 IV medication administrations

10 hospitals (one medical ICU, one surgical ICU, one general surgical unit, and one medical unit at each institution)

D: observation by two trained observers (nurse and/or pharmacist)

Tsang (2017)

[39]/Hong Kong

Project study/38 months

To describe the application of the point and calling method that is a rule-based behavior composed of various aspects and evaluate the intervention to reduce the high-alert medication using infusion and syringe devices

P: about 1100 nurses who had been taught how to implement the point and calling method. One hundred forty-five DOM, WM, APN, and RN were auditors and 709 nurses were audited by them

E: 5 high-alert medication incidents using infusion and syringe devices

21 wards from one hospital (1400 beds)

I: the point and calling methods on checking HAM using infusion and syringe devices developed by the workgroup comprised APNs and WMs

D: questionnaires on the perception of the point and calling methods from the participating wards and incidents reporting

Lyons (2018)

[33]/UK

Mixed methods/21 months

To describe the incidence, types, and severity of IV medication infusion errors

P: 1326 patients and 32 observers

E: 240 infusion errors and 1491 discrepancies of 2008 prescribed IV infusion

16 NHS hospital trusts

D: observation by two trained observers (usually a nurse and pharmacist)

Schnock (2018)

[34]/USA

Project study/3 years

To evaluate the preliminary effects of the infusion safety intervention bundle that was developed to decrease IV medication administration errors

P: 840 patients and 9 hospitals

- Pre-intervention: 418 patients

- Post-intervention: 422 patients

E: 2031 IV medication administrations

- Pre-intervention: 972

- Post-intervention: 1059

9 hospitals (adult medical/surgical units and medical/surgical ICUs at each institution)

I: infusion safety intervention bundle developed by a multidisciplinary research team

- Labeling/IV tubing intervention, unauthorized medication intervention, drug library use intervention

D: observation by two trained observers (nurse and/or pharmacist)

Taylor (2019)

[35]/USA

Retrospective study/1 year

To identify the frequency of medication errors with infusion pumps and analyze the contributing factors

P: healthcare professionals who reported patient safety-related incidents and serious events in a secure, web-based system

E: 1004 medication errors with infusion pumps

132 hospitals

D: a review of the events reported to the PA-PSRS during 2018

Schilling

(2022) [36]/Germany

Descriptive cross-sectional study (two-phase)/6 months

▪ The first phase: to develop a German pediatric HAM list

▪ The second phase: to identify DRP and related interventions for the HAM selected in the first phase

P: 42 pharmacists

- Response rate: the first phase (60%), the second phase (40%)

E: 216 DRPs

NA

D: a two-step survey by mailing to the participants