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Medication Errors in the Context of Hematopoietic Stem Cell Transplantation

A Systematic Review

Pereira Lermontov, Simone MSc; Carreiro Brasil, Simone MSc; Rezende de Carvalho, Magali MSc

doi: 10.1097/NCC.0000000000000613
Article: PDF Only

Background There have been numerous efforts by health institutions and professionals to prevent and reduce medication errors.

Objectives The aim of this study was to identify in the literature the incidence, related factors, consequences, and prevention mechanisms of medication errors in the context of hematopoietic stem cell transplantation.

Methods This is a systematic review carried out in the databases LILACS, PubMed, PMC, EMBASE, and CINAHL databases, from January 11 to 13, 2017.

Results Eleven studies were included in this review and presented in 4 categories of analysis. (1) occurrence—most of the medication errors were related to administration and prescription; (2) related factors—multicausal, highlighting issues including polypharmacy, lack of double checking, and similarity between the medications' names; (3) consequences—the main ones were associated with adverse reactions, with prolonged hospitalization time as outcome; (4) preventive measures—related to safe practices in pharmacotherapy, such as double check and application of the 10 rights of medication administration.

Conclusion Medication administration is an activity of great responsibility for nursing; however, in order to achieve a decrease in medication errors, prevention strategies are necessary for the whole health team.

Implications for Practice Practice improvements are needed including establishing institutional drug administration protocols and keeping them updated, using a computerized prescription system, and promoting patient safety with staff.

Author Affiliations: Instituto Nacional de Câncer (Mss Lermontov and Brasil) and Universidade Federal Fluminense (Ms Carvalho), Rio de Janeiro, Brazil.

The authors have no funding or conflicts of interest to disclose.

Correspondence: Simone P. Lermontov, MSc, Instituto Nacional de Câncer José Alencar Gomes da Silva–INCA, Praça da Cruz Vermelha, 23-7° andar, Centro, Rio de Janeiro, 23230-130 Rio de Janeiro, Brazil (; (

Accepted for publication March 7, 2018.

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