Prevalence and Nature of Medication Administration Errors in Health Care Settings

A Systematic Review of Direct Observational Evidence

Richard N Keers MPharm; Steven D Williams MPhil; Jonathan Cooke PhD; Darren M Ashcroft PhD


The Annals of Pharmacotherapy. 2013;47(2):237-256. 

In This Article


MAE remained common despite the growth in medication safety research in the last decade, and affect a median of 8.0% of TOE without timing errors (using OME numerator). Intravenous administration errors may be especially common. The marked variability in MAE rates and overlapping IQRs in this review may depend in part on differing study methods, settings and definitions. Medications within the categories nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives were associated with a high risk of MAEs. Given that these groups contain many medications that require time-sensitive administration and that wrong time, omission, and wrong dosage were the most frequently reported MAEs, they may constitute a target for future research. Along with determining with confidence the causes of MAEs, future research must seek standardization of relevant definitions and methods to best inform interventional strategies designed to maximize reductions in these errors.