An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings

Figures & data

Table 1. Search terms.

Category	Search terms
Medication errors	Medication error [MeSH] OR ((medication* OR transcrib* OR prescrib* OR dispens* OR administ*) adj3 (incident* OR mistake* OR error*))
Systematic review	Systematic review* OR Meta-analysis

Figure 1. PRISMA flow diagram of the study selection process.

Table 2. Characteristics of included reviews.

Author, Year	Study design	Context	Aim	Total number of primary studies	Inclusion criteria	Exclusion criteria
Al Rowily A, 2022 [47]	Systematic review and meta-analysis	Direct oral anticoagulants (DOACs) in adult patients	To estimate the prevalence, contributory factors, and severity of ME associated with DOACs	32	Studies which reported or investigated the rate of prescribing, administration, or dispensing errors associated with DOACs in adult patients (≥18 years)	Studies of ADE that are not classified as errors, as were review articles, letters, opinion papers, and editorials
Aldila F, 2021 [29]	Systematic review	Community-dwelling older adults	To identify the types of medicine self-administration errors (MSEs) and their contributing factors among community-dwelling older adults	11	Older adults (≥50 years), self-administering of prescription or non-prescription medicines. Outcomes which met the inclusion criteria were any types of administration errors, including but not limited to, wrong medicine, wrong dose, wrong frequency, and wrong administration route	Formal caregivers or healthcare professionals administered or assisted in the administration of medicines; the studies took place in institutional care settings, and studies were not primary literature, such as non-peer–reviewed publications, letters to editors, commentary, or conference presentations
Alshehri G, 2017 [39]	Systematic review	Mental health hospitals (inpatient and outpatient services)	To provide an up-to-date and critical assessment of the frequency and nature of ME and ADE in mental health hospitals	20	Studies that reported the rate of ME/ADE in one or more stage(s) of the treatment process for patients in mental health hospitals (inpatient and outpatient services), as were studies that examined the rate of unintentional medication discrepancies at the point of transition of care between mental health hospitals and other settings. Studies that examined the impact of interventions on ME or ADE rates were only included if a baseline error rate could be determined. Conference abstracts were included if they provided data sufficient to allow the rate of ME or ADE to be calculated	Studies that utilized incident reports as the primary source of collecting data (as they greatly underestimate the error rate) and studies that used an estimated denominator to calculate the rate of ME or ADE (as the provided rate may not be reflective of the actual rate). Studies that reported ME or ADE rates for a single drug, single drug class, or disease, as were studies that only examined specific prescribing, administration, transcription, or dispensing error subtypes. Studies that reported the rate of potentially inappropriate prescribing in mental health hospitals, as they were not considered to be ME. Review articles and studies that failed to differentiate between intentional and unintentional discrepancies using a robust method
Alsulami Z, 2013 [41]	Systematic review	Middle East countries	To identify and review studies of the incidence and types of MEs in Middle Eastern countries and identify the main contributing factors	45	All types of studies that reported the incidence of ME or identified the causes of MEs in the Middle East countries, either in adults or children	Reviews, letters, conference papers, opinions, reports, or editorial papers
Assiri G, 2018 [18]	Systematic review	Adults managed in community care contexts	To investigate the epidemiology of ME, error-related ADE, and risk factors for errors in adults managed in community care contexts (i.e. primary care, ambulatory, and home settings)	60	Adults (≥18 years) who were looked after in the community and living in their own or family homes without home healthcare or nursing home. The studied patients could have been self-managing, receiving care in primary care or ambulatory care settings, or any combination of the above. Studies that are population-based, cross-sectional or cohort studies, which were suitable to estimate the incidence and prevalence of ME or ADE. These study designs and case–control studies were considered eligible to study risk factors. Studies with prescribed and/or over-the-counter medications	Pediatric studies (<18 years) and studies on patients receiving care in hospital at home settings, in nursing homes, as hospitalized inpatients or in emergency departments. RCTs since these could not be used to reliably assess the incidence and/or prevalence and reviews. Incompletely reported studies (e.g. abstracts). Studies on illegal substance abuse, herbal products and those focusing on a single medication
Boytim J, 2018 [40]	Systematic review	Perioperative setting	To analyze the factors contributing to perioperative ME	19	Articles of any design involving the perioperative setting, ME, and human subjects	Studies not in the perioperative area; not related to MEs; animal studies; letters, opinions, reviews, or comments; and studies classified as case reports and interventions. Articles that noted the incidence of errors but had no specific details about ME and attributing causes
Di Muzio M, 2019 [50]	Systematic review	Shift work in inpatient nurses	To analyze the correlation between the clinical risk management and the occurrence of ME and the effects of the shift work (such as excessive fatigue and sleep deprivation after a shift) on inpatient nurses	19	Intervention studies, including RCT, Controlled Clinical Trials and all observational studies; papers reporting the administration of medications by registered nurses; studies performed in hospitals/inpatient settings; studies focusing on adult and pediatric patients; and peer-reviewed research articles	Studies reporting educational interventions; studies reporting the administration of medications by other HCP and studies reporting the prescription and the dispensing of drugs; studies carried out in outpatient centers, assisted living facilities and nursing homes; gray literature, such as dissertations, conference papers, proceedings
Dionisi S, 2021 [32]	Systematic review	Home care setting	To identify the main risk factors that affect the genesis of ME and the possible solutions to reduce ME in the home care setting	17	All study designs analyzing ME in the home care setting. The studies included must focus on the causes that lead to the generation of ME. Studies dealing with transitional care from any care setting to the home setting have been included. Studies in which the reference population is nurses, either as the sole reference population or in conjunction with other HCP	Grey literature (such as dissertations, conference papers, commentary, editorials) and literature reviews. All studies whose setting is different from home care, concerning hospital readmissions. Caregiver- and/or patient-centered studies, pediatric studies. Studies related to the treatment of specific diseases. The reference population is considered an exclusion criterion
Hansen C, 2016 [49]	Qualitative systematic review	Intern doctors	To synthesize the evidence of the qualitative literature on the views and experiences of intern doctors to identify the factors impacting safe prescribing and to examine the role of the pharmacist to assist in improving prescribing practices of interns	7	Only studies with qualitative data collection methods (e.g. semi-structured interviews, in-depth interviews, and original research) if they reported on newly qualified doctors’ views and opinions on prescribing, and if the data from the intern doctors could be isolated from the views of other levels of staff	NR
Keers R, 2013 [35]	Systematic review of quantitative and qualitative evidence	Inpatient	To systematically review and appraise empirical evidence relating to the causes of MAE in hospital settings	55	Studies that reported data on the causes of MAE made in inpatient hospital settings. Identified causes in relation to specific errors or near misses that staff members either made themselves or were directly involved with	Review articles, conference, abstracts if they did not provide enough relevant data. Studies that reported on results based on simulation, or concerned with only one subtype of MAE, as were studies reporting results obtained from incident or case reports as it could not be determined whether the person reporting the incident had been directly involved
Lampert A, 2014 [48]	Systematic review	Transdermal patches	To systematically review the literature on nature and etiology of potential administration errors associated with the use of transdermal patches and characterized these errors according to the affected administration subprocess	42	All types of publication that reported an actual faulty administration of a transdermal patch. Demographic data (age, sex) were considered mandatory to eliminate duplicate reports and prevent subsequent distortion of results regarding the frequency of errors	Solely characteristics of a new transdermal patch were presented; the safety profile of a drug in a transdermal patch was evaluated; ADR were reported while the transdermal patch was used correctly; intentional misuse, abuse, or suicide because prevention strategies would largely differ from those applicable for unintentional errors; or no indication for causality between the faulty administration and the outcome was given
Lermontov S, 2018 [38]	Systematic review	Hematopoietic stem cell transplantation	To identify in the literature the incidence, related factors, consequences, and prevention mechanisms of ME in the context of hematopoietic stem cell transplantation	11	All study designs that report ME in the bone marrow transplantation scenario	Conference, abstracts, editor letters, book chapter, editorial, review, comment, and dissertation/thesis
Lopez-Pineda A, 2022 [36]	Systematic review	Pediatric ME by parents or caregivers at home	To review the current literature on the frequency of pediatric ME by parents or caregivers at home, their associated factors, and pediatric ME reporting systems	19	Original articles on ME, either prescribed or non-prescribed drugs, that parents or other caregivers of children make at home, influencing factors and pediatric ME reporting systems. Any type of study design if they investigated ME in pediatric population in the outpatient setting (at home)	Studies on therapeutic adherence, any type of review, non-citable paper, such as editorials or letters to the editor, or studies for which access to complete information was not available, even after contacting the authors
Mansouri A, 2014 [43]	Systematic review	Iran	To detect and evaluate the studies on source of ME, reasons for ME under-reporting, preventive measures of ME and the most common drugs related to ME in Iran	25	All types of original studies on adults and children that reported sources of ME, reasons for not reporting ME, preventive measures of ME, and most common drugs involved in ME in Iran	Letters, case reports, conference papers, organizational reports, opinions, or editorial papers. Articles focused on medical errors and nursing practice errors. Articles on preventive measures which were solely focused on usability and acceptability of the measures themselves, not on the outcome of reducing ME
Marznaki Z, 2020 [44]	Systematic review	Iran emergency departments	To review the literature describing the prevalence and factors affecting ME among emergency ward nurses in Iran	8	Full-text, peer-reviewed published studies that evaluated ME among emergency ward nurses in Iran	Studies conducted among any other healthcare providers, or among nurses who worked in other wards. Reviews, letters, RCTs, case studies, conference papers, opinions, dissertations, reports, and editorial papers. No access to full text. Grey literature as they usually do not portray the whole picture of the results, and when fully published, the results may change substantially
Mekonnen A, 2018 [45]	Systematic review	African hospitals	To systematically investigate the literature on the extent of ME and ADE, and the factors contributing to ME in African hospitals	41	Peer-reviewed original published articles, irrespective of the study design, that investigated the frequency and nature of ME and/or ADE. Studies that addressed ADE were included only if injuries due to medications were reported. Studies that assessed HCP experiences or possible causes of ME. Studies should be carried out in an African hospital setting	Studies that investigated failures in optimizing drug therapy (e.g. dosage adjustment in renal failure patients), pharmaceutical issues, events caused by single drugs or drug classes or disease condition, and studies that aimed to assess knowledge and attitude to ADR reporting. Studies evaluating non-adherence to medication or self-harm. Conference abstracts, case studies, commentaries, and reviews
Mira J, 2015 [30]	Systematic review	Self-administering medications at home	To review and describe the methodological approaches and results of published studies on the frequency, causes, consequences, and avoidance of ME committed involuntarily by patients on self-administering medicines at home	69	Studies that focused on empirical, review or assessment work in relation to errors made by patients in their homes. Studies on types of errors on taking medication prescribed by a doctor or as the result of self-medication, factors that brought them about and their consequences. Studies on involuntary non-adherence that contributed data on ADE due to forgetting one’s medication or failing to correctly follow the therapeutic regimen. Peer-reviewed research	Studies on the frequency and causes of voluntary non-adherence. Studies on self-medication when not related to the occurrence of patient harm according to the classification of errors by Buetow et al. Studies on patients acting as vigilant partners in safety (second control) thereby helping professionals avoid ADE or on the use of medicines for suicide attempts
Parand A, 2016 [33]	Systematic review	Domiciliary setting	To review studies of how carers cause and/or prevent MAE within the patient’s home; to identify types, prevalence, and causes of these MAE and any interventions to prevent them	36	Errors occurred in the home, carers were responsible for the delivery of medication and empirical data were provided. Papers describing multiple case studies and qualitative studies where there was more than one care recipient participant	Papers describing a single case study, such as a MAE legal case. Papers that did not report data for carer-caused MAE separately to other ME or from other administrators (e.g. patients themselves), unless over 80% of combined data related to carers
Salmasi S, 2015 [46]	Systematic review	Southeast Asian countries	Aimed systematically to identify and review research done on ME in Southeast Asian countries to identify common types of ME and estimate its prevalence	17	All study designs. Patients of all ages from Southeast Asian countries	Reviews, letters, case studies, conference papers, opinions, reports, or editorial papers
Salmasi S, 2017 [37]	Systematic review	Older people	To systematically review studies on the incidence and categories of ME in older people in any setting	18	Original peer-reviewed research studies if they comprised ME in people aged ≥55 years. The more conservative cutoff point of 55 years was chosen to ensure no relevant study was excluded. Studies were only included if they were designed to assess ME	Studies focusing on ME caused by patients, such as self-medication. Unpublished or gray literature. Studies that reported ME as a secondary or additional outcome and those not specifically designed to assess and analyze ME. The prescribing of Beers medication was not considered a ME
Santesteban E, 2015 [34]	Systematic review	Neonatal Intensive Care Units (NICU)	To review the literature on the frequency and types of ME in NICU and the effectiveness of preventive strategies	13	Original studies or systematic reviews that measured ME in NICU and original studies or systematic reviews that measured interventions to reduce ME in NICU	Case studies or case reports, studies about errors in parenteral nutrition preparation, editorial articles or narrative reviews of ME, and abstracts without concrete results
Schroers G, 2020 [51]	Systematic review	Not specific	To critique and synthesize the qualitative evidence on perceived causes of MAE as reported by nurses in health-care settings	16	Studies that used a qualitative or mixed methods design and reported qualitative data on nurses’ perceived causes of MAE in health-care settings	NR
Sears K, 2012 [31]	Systematic review	Community setting	To identify the incidence, prevalence and contributing factors associated with ME for children and adults in the community setting	21	All types of studies that included adults and children living in the community (including home/residential homes) that have experienced a ME and evaluated the incidence, prevalence and contributing factors	NR
Snijders C, 2007 [26]	Systematic review	NICUs	To examine the characteristics of incident reporting systems in NICU in relation to type, etiology, outcome, and preventability of incidents	10	Systematic reviews, RCT, observational studies, or qualitative research concerning incident reporting. NICU data can be extracted from articles	Non systematic reviews, expert opinion, case reports, letter from the editor
Thomas B, 2019 [42]	Systematic review	Hospitalized patients in Middle Eastern countries	To critically appraise, synthesize and present the evidence of ME amongst hospitalized patients in Middle Eastern countries, specifically prevalence, nature, severity, and contributory factors	50	Primary research studies of any design conducted in hospital settings in the Middle East (defined) which quantified ME (i.e. prescribing, administration or dispensing errors). Studies which reported error nature, severity or associated causative factors were also included	Studies of ADE which were not classified as errors, as were review articles, letters, opinion papers, editorials, and conference abstracts
Tully M, 2009 [28]	Systematic review	Inpatient	To identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyze it qualitatively and synthesize conclusions	17	Studies that reported on the causes of and/or factors associated with prescribing errors in handwritten prescriptions written by doctors for adult and/or child hospital inpatients. Studies reporting ME more broadly were only included if they describe the causes of or factors associated with prescribing errors in sufficient detail to allow extraction and analysis to be carried out. Any study design with data concerning causes and associated factors collected empirically	Studies where causality or associated factors were surmised (e.g. based on professional experience of the data collector). Conference abstracts
Wimpenny A, 2010 [28]	Systematic review	Acute care settings	To undertake a comprehensive systematic review of roles and systems for preventing ME during routine medication administration in hospital-based acute care settings	19	Participants were nurses, pharmacists, pharmacy technicians, medical and surgical staff, and adult patients in hospital-based, acute care settings. 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. Quantitative studies of ME error rates for differing medication systems and roles of those administering medications. Qualitative and descriptive studies of perceived causes of errors	NR

ME: medication errors; ADE: adverse drug events; RCT: randomized controlled trials; HCP: healthcare providers; ADR: adverse drug reactions; NR: not reported; MAE: medication administration errors

Table 3. Data pertaining to medication errors.

Author, Year	Terminology	Definition	Methodology for classifying ME	Classification of ME
Al Rowily A, 2022 [47]	Medication errors	Worked with the definitions provided by original studies	Medication use processIncident type (type of prescribing errors)	Prescribing, administration, dispensing errors
Aldila F, 2021 [29]	Medicine self-administration errors (MSE)	A deviation by the patients or their caregivers from the prescriber’s medication orders or the manufacturer’s administration instructions during the medicine administration process (adopted)	Types of MSE were classified in accordance with how they were reported in the original studiesIncident type (type of prescribing errors)	Dosing error, missed dose, wrong medicine, duplicity of medicines, incorrect preparation methods, incorrect administration methods, wrong administration route, wrong administration time, wrong frequency, incorrect spacing (time period between doses), and use of expired medicines
Alshehri G, 2017 [39]	Medication errors	NCCMERP definition (adopted)	Medication use processIncident type (type of prescribing errors)	Overall ME, prescribing, administration, transcribing, dispensing errors
Alsulami Z, 2013 [41]	Medication errors	Not reported	Medication use processIncident type (type of prescribing errors)	Prescribing, transcribing, administration errors
Assiri G, 2018 [18]	Medication errors	Worked with the definitions provided by original studies	Medication use process	Prescribing, monitoring errors
Boytim J, 2018 [40]	Medication errors	Not reported	Not done	Not done
Di Muzio M, 2019 [50]	Medication errors and adverse events interchangeably	Not reported	Not done	Not done
Dionisi S, 2021 [32]	Medication errors	Not reported	Not done	Not done
Hansen C, 2016 [49]	Prescribing error	Not reported	Not done	Not done
Keers R, 2013 [35]	Administration errors	A deviation from the prescriber’s medication order as written on the patient’s chart, manufacturers’, instructions, or relevant institutional policies (adopted)	Not done	Not done
Lampert A, 2014 [48]	Medication errors	Not reported	Not done	Not done
Lermontov S, 2018 [38]	Pediatric medication error at home	Any preventable and unintentional deviation from the appropriate use of prescribed or non-prescribed pediatric medication, committed by parents or caregivers in the outpatient setting	Incident type (type of errors)	Dosing errors, time administration errors, frequency errors, medication preparation method, self-decided treatment discontinuation, wrong medicine, expired medication,
Lopez-Pineda A, 2022 [36]	Medication errors	Not reported	Not done	Not done
Mansouri A, 2014 [43]	Medication errors	Not reported	Not done	Not done
Marznaki Z, 2020 [44]	Medication errors	NCCMERP definition (adopted)	Medication use processIncident type (for all stages)	Ordering, transcribing, dispensing, administration, and during medication history taking
Mekonnen A, 2018 [45]	Medicine self-administration errors (MSE)	Not reported	Not done	Not done
Mira J, 2015 [30]	Medicine self-administration errors (MSE)	Not reported	Not done	Not done
Parand A, 2016 [33]	Administration errors	Any deviation between the medication prescribed and that administered (adopted)	Not done	Not done
Salmasi S, 2015 [46]	Medication errors	NCCMERP definition (adopted)	Medication use processIncident type (type of prescribing errors)	Medication use process: prescribing, administration, dispensing, preparation, transcribing Incident type: wrong dose, omission error, incorrect time, wrong drug, incorrect administration technique, wrong dose form
Salmasi S, 2017 [37]	Medication errors	NCCMERP definition (adopted)	Medication use process	Prescribing, administration, dispensing, transcribing
Santesteban E, 2015 [34]	Medication errors	Not reported	Not done	Not done
Schroers G, 2020 [51]	Administration errors	Not reported	Not done	Not done
Sears K, 2012 [31]	Medication errors	Worked with the definitions provided by original studies	Worked with the classification provided by original studies Medication use process was identified	Prescribing, administration, dispensing errors
Snijders C, 2007 [26]	Medication errors (study concerned medical errors with focus on ME)	Worked with the definitions provided by original studies	Not done	Not done
Thomas B, 2019 [42]	Medication errors	Not reported	Medication use process	Prescribing, administration dispensing errors
Tully M, 2009 [28]	Prescribing errors	Worked with the definitions provided by original studies	Not done	Not done
Wimpenny A, 2010 [28]	Administration errors	Not reported	Not done	Not done

ME: medication errors

Table 4. Data pertaining to contributory factors to medication errors.

Author, Year	How many studies reported on contributory factors	Terminology used to describe contributory factors	Definition of contributory factors
Al Rowily A, 2022 [47]	27 out of 32 (84.4%)	Contributory factors, causation	Not reported
Aldila F, 2021 [29]	7 out of 11 (63.6%)	Contributory factors	Not reported
Alshehri G, 2017 [39]	5 out of 20 (25%)	Factors that increase therisk/rate of error	Not reported
Alsulami Z, 2013 [41]	12 out of 45 (26.7%)	Contributory factors, causes	Not reported
Assiri G, 2018 [18]	36 out of 60 (60%)	Risk factors	Not reported
Boytim J, 2018 [40]	All studies (part of the inclusion criteria)	Contributory factors	Not reported
Di Muzio M, 2019 [50]	All studies (part of the inclusion criteria)	Factors, reasons	Not reported
Dionisi S, 2021 [32]	All studies (part of the inclusion criteria)	Risk factors, causes	Not reported
Hansen C, 2016 [49]	All studies (part of the inclusion criteria)	Factors influencing/ affectingprescribing behavior	Not reported
Keers R, 2013 [35]	All studies (part of the inclusion criteria)	Causes	Reasons reported to the researcher by the person directly involved with a specific administration error or near miss as being wholly or partly responsible for said error (developed by authors)
Lampert A, 2014 [48]	8 out of 42 (19%)	Contributing factors, causes, rootcause, etiology	Not reported
Lermontov S, 2018 [38]	8 out of 11 (72.7%)	Related factors	Not reported
Lopez-Pineda A, 2022 [36]	14 out of 19 (73.7%)	Associated/influencing/risk factors	Any factor that increased the chance of parents or caregivers made a ME at home (developed by authors)
Mansouri A, 2014 [43]	12 out of 25 (48%)	Contributory factors, sources	Not reported
Marznaki Z, 2020 [44]	All studies	Contributory factors, factorsaffecting ME	Not reported
Mekonnen A, 2018 [45]	15 out of 41 (36.6%)	Contributory factors, causality	Not reported
Mira J, 2015 [30]	36 out of 69 (52.2%)	Causal factors, causes	Not reported
Parand A, 2016 [33]	25 out of 36 (69.4%)	Contributory factors, causes	Not reported
Salmasi S, 2015 [46]	15 out of 17 (88.2%)	Contributory factors, root causes	Not reported
Salmasi S, 2017 [37]	13 out of 18 (72.2%)	Contributory factors, riskfactors, reasons	Not reported
Santesteban E, 2015 [34]	5 out of 13 (38.5%)	Causes	Not reported
Schroers G, 2020 [51]	All studies (part of the inclusion criteria)	Contributory factors, causes	Not reported
Sears K, 2012 [31]	10 out of 21 (47.6%)	Contributory factors, causal factors, causative factors, predictors	The circumstances, actions or influences which are thought to have played a part in the origin or development of an incident or to increase the risk of an incident (adopted from WHO)
Snijders C, 2007 [26]	All studies	Contributory factors, etiology, factors, etiological factors	Not reported
Thomas B, 2019 [42]	24 out of 50 (48%)	Contributory factors, causative factors, causes	Not reported
Tully M, 2009 [28]	All studies (part of the inclusion criteria)	Factors associated, causes	-Factors associated: variables that were linked with the prevalence of specific prescribing errors by the researchers-Causes: reasons reported to the researchers by the prescriber, in structured or unstructured interviews (developed by authors)
Wimpenny A, 2010 [28]	11 out of 19 (57.9%)	Causes, reasons	Not reported

Table 5. Contributing factors to medication errors.

Author, Year	Methodology to identify and classify contributory factors	Error classes		Examples	Most reported
Al Rowily A, 2022 [46]	Reason’s accident causation model	Active failures	Slips	Duplicate therapy, transcription errors, dispensing errors	Active failures: mistakes
			Lapse	Acronym errors, wrong label
			Mistakes	Wrong dose (non-consideration of renal function), wrong indication
			Violation	Doctor not writing the order in time
		Error provoking condition		Lack of knowledge and experience, inadequate monitoring, system errors, failure staff to follow policy, inadequate laboratory results, poor communication, distraction, work overload
		Latent conditions		Lack of medication reconciliation service, lack of training
Aldila F, 2021 [28]	Not reported	Not reported		Complex regimens, cognitive decline, lack of knowledge, negative attitudes and beliefs toward medicines, decline in physical ability, lack of social support, multiple chronic conditions, poor collaboration between patients/HCP and among HCP, pharmaceutical products and packaging design, confusion about compliance aids, limited health literacy, absence of error detection mechanisms, absence of patient education	Complex regimens
Alshehri G, 2017 [38]	Not reported	Not reported		Senior physicians, use of an electronic prescription pro forma, number of medications/doses, interruptions, patient load, nonoral route of administration, presence of organic brain disease (e.g. dementia), swallowing difficulties	Not reported
Alsulami Z, 2013 [40]	Not reported	Not reported		Lack of knowledge, poor compliance with guidelines, lack of reporting of ME, heavy workload and new staff, miscommunications between HCP	Lack of knowledge
Assiri G, 2018 [18]	Predefined categories	Patient-related		Polypharmacy, increased age, number of diseases, female, low level of education, hospital admission, middle family income	Not reported
		Healthcare professionals-related		Multiple physicians involved in care, family medicine specialty, age ≥51 years, male, frequent changes in prescription, not considering prescriptions of other physicians, inconsistency in the information and outpatient clinic visits
		Medication-related		Multiple drug storage locations, expired medication, discontinued drugs repeats retained, hoarding of drugs, therapeutic duplication, no administration routine, poor adherence, confusion between generic and trade names, multidose drug dispensing users, receiving anticoagulant therapy, use of over-the-counter drugs
Boytim J, 2018 [39]	Factors grouped according to emergingthemes (not predefined)	Types of errors		Wrong dose, omission, wrong route, wrong dosage form	Performance deficits, distraction, haste, inattention, poor communication, knowledge deficits, labeling mistakes, and syringe swaps
		Causes of errors		Labeling mistakes and syringe swaps, performance deficit, distraction, poor communication, haste, inattention, knowledge deficit
		Human factors		Haste, stress, pressure, distraction, decreased vigilance, fatigue, inaccurate medication reconciliation, patient lack of understanding, and knowledge deficit related to patient allergies
		Medication types		Analgesics, antibiotics, vasopressors
		Environmental factors		Transfers, fragmentation, change providers, work overload, federally owned facilities, facilities with 100 to 499 beds (compared to <100 or > 500), anesthesia induction period, maintenance period, longer procedures, procedures performed during the day
		Patient characteristics		Low physical status, male, acuity
Di Muzio M, 2019 [49]	Not reported	Study focused on shift works only		Occasional night shifts, reduced staffing, long shifts, work overload, sleep quality and quantity, stress, fatigue, workflow interruptions	Not reported
Dionisi S, 2021 [31]	Factors grouped according to emerging themes (not predefined)	Transition of care		Lack of complete documentation particularly medications, poor communication, technology errors, patient-related factors (elderly, polypharmacy, chronic diseases)	Not reported
		Medication reconciliation		Lack of a standardized process, lack of single documentation that reports the entire patient history, poor communication, poor flow of information
		Multidisciplinary team		Poor interprofessional communication and with the patient, low health literacy, cognitive and functional impairment, inadequate integration of the pharmacist into the care team
Hansen C, 2016 [48]	Thematic synthesis (predefined)	Environmental factors		Time constraints, poor communication, defenses (I know someone else will check it), hierarchical structures, rotation	Not reported
		Patient characteristics		Complexity, poor communication, patients’ influence
		Individual factors		Wellbeing (workload), lack of knowledge, attitude and awareness, responsibility, experience
Keers R, 2013 [34]	Reason’s accident causation model	Unsafe acts		Slips, lapses, knowledge-based mistakes, deliberate violations	Slips, lapses, knowledge-based mistakes, communication, work overload, medicine supply and storage
		Error-provoking conditions (local workplace factors)		Inadequate written communication, problems with medicines supply and storage, work overload, problems with ward-based equipment (access, functionality), patient factors (acuity), staff health status (fatigue, stress), interruptions
		Organizational (high-level) decisions		Poor feedback on errors and lack of nurse input in the process, lack of hospital policy or misguided policy (low nurse staffing), logistical strategy decisions revolve around clashes of other ward activities with medication administration, look or sound alike medication may have roots beyond hospitals with the pharmaceutical industry
		Latent conditions		Local working culture and high-level managerial decisions
Lampert A, 2014 [47]	Not reported	Not reported		Lack of knowledge and awareness of the importance of a correct administration practice, patch designs	Not reported
Lermontov S, 2018 [37]	Not reported	Not reported		Over-the-counter medications, polypharmacy, lack of double checking, look alike and sound alike medications, stress, dose calculation error, poor communication, illegible prescriptions	Not reported
Lopez-Pineda A, 2022 [35]	Not reported	Not reported		Poor comprehension, complex regimens, low health literacy, primary language of the parent was different from the language of written discharge instructions, male sex, younger age, polypharmacy, use of dropper (versus cup and syringe), use of a teaspoon-only label, receiving text only instructions (versus text and pictogram), decreasing child age, limited understanding about medications, lack of reassessment by HCP	Not reported
Mansouri A, 2014 [42]	Framework of factors influencing clinical practice and contributing to adverse events (with modification, added an extra category entitled medication)	Individual factors		Inadequate knowledge, miscalculations of doses, physical and mental health	Individual factors: inadequate knowledge
		Work environment		Heavy workload, working overtime, nurses’ burnout, little time spent with patient
		Organization and management		Shortage of workforce (understaffing)
		Team		Illegibility of orders or patient charts
		Tasks		Lack of guidelines
		Medications		Name similarity
Marznaki Z, 2020 [43]	Not reported	No attempt at classifying by authors		Reduced staffing, inappropriate nurse-patient ratios, inadequate knowledge, demographic factors (nurses’ age, gender, and work experience), busy nature of emergency wards, managerial lapses	Reduced staffing and inappropriate nurse-patient ratio
Mekonnen A, 2018 [44]	Factors grouped according to emerging themes (not predefined)	Individual factors		Fatigue, confusion, memory lapses, rushing, inadequate monitoring/reporting, inadequate knowledge/training, rule violation, inappropriate administration technique, low morale	Individual factors: fatigue and inadequate knowledge/ training Environmental factors: workplace distraction and work overload
		Working environment		Work overload, distraction, busyness, lack of resources (e.g. equipment), time of the day
		Team		Communication deficits, no senior support
		Task		Lack of documentation, labeling deficits, transcription error, illegible writing, multi-tasking, unfamiliar patient, look-alike drug names/labeling, syringe swap, misidentification of drugs/ampoules, careless checking/not checking
Mira J, 2015 [29]	Factors grouped according to emerging themes (not predefined)	Intrinsic factors		Patients’ profile (age, cognitive state, polypharmacy), level of health literacy	Not reported
		Extrinsic factors		Quality of the information provided, communication with caregivers, complexity of use dispensing devices
Parand A, 2016 [32]	Contributory factors inductively identified and grouped into a new framework	Individual care recipient factors		Younger child age	Not reported
		Individual carers factors		Age of carer, educational level of carer, carer’s time and other responsibilities, language of carer, health of carer, carer marital status
		Medication factors		Polypharmacy, type of medication, route of administration, medication supply
		Environmental factors		Storage, equipment
		Prescription communication factors		Communication with healthcare professionals & carers’ understanding of instructions or medication/illness, dosage change
		Psychological factors		Panic/cognitive failure, fear of spillage, carer-to-carer communication
Salmasi S, 2015 [45]	Not reported	Not reported		Factors extrapolated from original studies: staff shortage, work overload, distraction, incorrect interpretation of prescription/medication chart, lack of knowledge, lack of experience Factors provided based on the authors of the reviews assessment: poorly designed work environments and systems, patients factors (forgetfulness, lack of cooperation or confusion)	Not reported
Salmasi S, 2017 [36]	Not reported	Not reported		Polypharmacy, inappropriate administration scheduling, understaffing, similar packaging, stress and time constraints, lack of staff training, medications associated with complex tasks (crushing), interruptions during ward rounds	Not reported
Santesteban E, 2015 [33]	Not reported	Not reported		Human factors, use of unlicensed medicines	Human factors
Schroers G, 2020 [50]	Thematic synthesis (methods predefined)	Knowledge-based factors		Lack of knowledge about medications, protocols, technology, calculations, lack of skills required for administration, misinterpretation of preparation protocols	Contextual factors (most common): heavy workloads and interruptions Knowledge-based factor: medication knowledge Personal factors: fatigue and complacency
		Personal factors		Complacency, lack of confidence, fear of looking incompetent, overconfidence, negligence, forgetfulness, lack of attentiveness, not following protocol, practice beyond scope of practice, fatigue, tendency to make assumptions, stress, lapses, nervousness, lack of concentration, lack of care, unpreparedness, drowsiness, talking, multitasking, personal or family health issues, deliberate deviations from guidelines
		Contextual		Interruptions, poor communication, challenging professional relationships, understaffing, heavy workloads, lack of supervision/support, inexperience, lack of training, improper physical working conditions, work-related pressure, lack of time, unsafe practice norms
Sears K, 2012 [30]	Analyzed using the Conceptual Framework for the International Classification for Patient Safety proposed by the WHO	Staff factors		Cognitive factors: lack of knowledge, confusion about medicationsPerformance factors: dosing errors, misreading prescriptions, calculation errorsBehavior factors: fatigue, carelessness, lack of concentrationCommunication factors: poor communication, lack of communication between doctor and patient or between staff, patient, and carers Emotional factors: low satisfaction	Not reported
		Patient factors		Cognitive factors: confusion, lack of awareness of medicationsPerformance factors: dosing errors
		Work/environment factors		Physical environment/infrastructure: hot, airless, poorly lit, short of space, busy environment, pressured, noisy and fraught, interruptions
		Organizational/service factors		Resources/workload: busy, distraction
		External factors		Products, technology, and infrastructure: similar looking medications/containers/ packaging, similar drug names
Snijders C, 2007 [25]	Not reported	Not reported		Failure to follow procedures, inattention, poor documentation or communication, lack of training, negligence, poor regulation, incorrect orders, faulty preparation, increased level of care, verbal orders differed from written order, lack of double check, dose miscalculations-Some studies reported the stage of the medication use process or the incident type as the contributory factor	Not reported
Thomas B, 2019 [41]	Reason’s accident causation model	Active failure	Slips	Look-alike sound-alike medications, selecting wrong medication, wrong patient, memory lapses	Active failures: slips, lapses, and mistakes Error-provoking conditions: lack of knowledge, insufficient staffing levels Latent conditions: heavy workload
			Lapses	Dispensing errors, failure to give medication, lack of documentation, faulty dose checking
			Mistakes	Wrong dose, wrong packaging, incomplete medication orders, incorrect transcription
			Violation	Use abbreviations, poor adherence to protocol, using acronyms
		Error- provoking conditions		Fatigue, illegible handwriting, work overload, patient condition (illiteracy, elderly)
		Latent conditions		Lack of training, lack of staffing, poor communication, supervisory issues, lack of policy and procedures, performance deficit
Tully M, 2009 [26]	Reason’s accident causation model	Active failure	Slips	Skill-based	Active failure: mistake
			Lapses	Memory-related
			Mistakes	Knowledge-based, rule-based
			Violation	Inadequate monitoring, not following policy
		Error- provoking conditions		Lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between HCP
		Latent conditions		Reluctance to question senior colleagues, inadequate provision of training
Wimpenny A, 2010 [27]	Results were combined in a meta-aggregative view	Quantitative data from nurses’ perception		Nurse fails to check patients name band with the medication administration record, tired and exhausted, order difficult to read or illegible, distracted by other patients, coworkers or events, dose miscalculation
		Qualitative data from nurses’ perception		External factors: use of policies, protocols, and guidance; context and organization of care; and roles of people within the systemInternal factors: interpersonal skills and relationships; individual knowledge and skills; and personal responsibility
		Qualitative data from patients’ perception		Patients not included in the medication administration process; nurses may not listen to their concerns; and patients unaware of the medication administration process and the drugs being administered

HCP: healthcare providers; ME: medication errors

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