Medication Errors among Iranian Intensive Care Nurses: A Systematic Review : Iranian Journal of Nursing and Midwifery Research

Secondary Logo

Journal Logo

Review Article

Medication Errors among Iranian Intensive Care Nurses: A Systematic Review

Marznaki, Zohreh Hosseini; Zeydi, Amir Emami1; Ghazanfari, Mohammad Javad2; Salisu, Waliu Jawula3; Amiri, Mehdi Mohammadian4,; Karkhah, Samad5,6,

Author Information
Iranian Journal of Nursing and Midwifery Research 28(2):p 123-131, Mar–Apr 2023. | DOI: 10.4103/ijnmr.ijnmr_310_21
  • Open



Patient safety is still a major challenge and the most important concern in the world’s health systems.[1–3] Medication Error (MEs) are one of the most important factors that could jeopardize a patient’s safety. According to the World Health Organization (WHO), MEs are the second most common factor that threatens patient safety.[3]

Patients admitted to the Intensive Care Units (ICU) are more vulnerable to MEs than patients in the other units because of high complexity of care, frequent use of high-risk medications, and patients’ altered end-organ function which can affect a drug’s pharmacokinetics and pharmacodynamics.[4,5] The occurrence of MEs is associated with an increased risk of several adverse outcomes in critically ill ICU patients. Previous evidence has shown that the prevalence of MEs in the ICU ranges between 9.4% and 73.43%.[4,6–8] Moreover, it has been revealed that MEs are responsible for 78% of all serious medical errors in the ICU.[9]

Nurses play a key role in the care of patients, management of drug measures, and improvement of patient safety due to their spending more time with critically ill ICU patients.[10,11] The nurses are primarily responsible for medication administration and they usually spend about 40% of their time on it.[12] The assessment of the pattern, prevalence, and factors associated with MEs made by critical care nurses can help nurse managers develop innovative solutions for, define a clear strategy for reducing the incidence of, and prevent potential negative outcomes of MEs among critically ill ICU patients. Therefore, this systematic review was conducted focusing on prevalence, factors, and outcomes associated with MEs made by ICU nurses in the context of Iranian healthcare.

Materials and Methods

This systematic review was carried out based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for identification, screening, and eligibility of the studies.[13]

An extensive search was conducted in electronic databases including MEDLINE/PubMed, Web of Science, Scopus, and Google Scholar, as well as Persian databases such as Magiran and Scientific Information Database (SID) using related keywords such as “medication error”, “prescribing error”, “medication incidents”, “medication administration error”, “drug administration error”, “drug error”, “nurses”, “nursing”, “intensive care unit”, “ICU”, “critical care”, and “Iran” and the Persian equivalent of these keywords, from the first article written in this field to those published on March 30, 2021. Medical Subject Headings (MeSH) was used to extract target-related keywords. The language of the studies was limited to Persian and English. The search strategy of the databases is presented in the selection process of studies was conducted by two researchers (ZH and MG), independently. In case of disagreement between the researchers as to whether a study met the eligibility criteria, a third researcher (AE) appraised the study and then selected or rejected it by consensus. The gray literature was not actively searched because they usually do not portray the whole picture of the results, and when fully published the results may change substantially.

EndNote X8 software was used to manage the included studies. In the first step, the researchers excluded duplicate studies electronically and manually. Then, according to the inclusion and exclusion criteria, the title and abstract of the studies were screened. Finally, the researchers screened the full-text of eligible articles. Also, the researchers screened a list of included study references for any relevant references missing in the database search. The study selection process was conducted by two researchers (SP and WJ) independently. In case of disagreement between researchers as to whether a study met the eligibility criteria, the third researcher (SK) appraised the study and then selected or rejected it by consensus.

The inclusion criterion was published original articles focusing on the prevalence and factors related to ME made by Iranian ICU nurses. The researchers excluded studies such as case reports, experimental studies, editorial letters, conferences, and reviews. Also, studies that evaluated ME made by nurses working in the Pediatric Intensive Care Unit (PICU) or Neonatal Intensive Care Unit (NICU) were excluded. The corresponding authors were contacted for articles with no access to their full text or for articles that were missing relevant data. In case of non-response of the corresponding author, the study was removed.

Information such as the first author’s name, year of publication, location, design, sample size, male-to-female ratio, age, overall work experience and ICU, type of work shift, type of drug key results, including factors and outcomes associated with MEs, and total prevalence of ME were extracted from included studies using a predesigned extraction form. The appraisal tool for cross-sectional studies (AXIS tool)[14] was used to assess the quality of the included studies. AXIS evaluates the quality of studies using 20 items with a two-point Likert, including “yes” (score of 1) and “no” (score of 0). This tool evaluates report quality (seven items), study design quality (seven items), and the possible introduction of biases (six items). Finally, AXIS rates the quality of studies at three levels: high (70% to 100%), fair (60% to 69.9%), and low (0% to 59.9%).[14] Data extraction and quality assessment were performed by two researchers (ZH and AE), independently. In case of disagreement between researchers as to whether a study met the eligibility criteria, the third researcher (SK) appraised the study and then selected or rejected it by consensus. At this stage, factors associated with MEs made by ICU nurses were divided into subgroups of management and human, environmental, drug-related, and demographic factors [Table 2]. Finally, the available evidence was summarized based on the research question.

Table 1:
Basic characteristics of the included studies in this systematic review
Table 2:
Factors associated with medication errors in intensive care nurses

Ethical considerations

The protocol of this study was approved by the institutional ethics committee of Mazandaran University of Medical Sciences (IR.MAZUMS.REC.1399.8597). The authors avoided plagiarism in any form in writing the present study. The results of the analysis were quite honest. The authors avoided data fabrication. They never manipulated the data for their benefit.


Study selection

A total of 908 studies (MEDLINE/PubMed = 99, Web of Science = 109, Scopus = 50, Google Scholar = 529, Magiran = 96, and SID = 25) were yielded by database search and 4 studies by evaluating the reference list of included studies. After excluding duplicate articles, 602 studies remained. Then, after screening the title and abstract of the articles 372 studies were removed due to inconsistencies with the purpose of the present study, and 171 studies were removed due to the non-cross-sectional nature of the studies. After screening the full text of 55 studies, 25 articles were removed due to inappropriate study design or outcomes, and 15 articles were removed due to lack of relevant information. Finally, 15 studies[7,8,15–27] were included in this systematic review. Flow diagram of the study selection process is presented in Figure 1.

Figure 1:
Flow diagram of the study selection process

Study characteristics

Based on the AXIS tool, the quality score of the included studies was 60%–80%. Fourteen studies[7,8,15–25,27] had a high quality and one study[26] had a fair quality [Figure 2]. A total of 1,277 ICU nurses were enrolled in 15 included studies.[7,8,15–27] All studies had a cross-sectional design. The age range of ICU nurses was 29–58 years with a mean (SD) age of 32.28 (5.52) years. Eleven studies[7,8,15–17,19,20,23–26] reported the nurses’ gender (85.03% of nurses were women). In five studies,[7,19,24,26,27] the overall work experience of ICU nurses was reported (total mean (SD) of 7.87 (4.85) years). In four studies,[8,19,26,27] the ICU work experience of nurses was reported (total mean (SD) of 5.08 (3.96) years). Five studies[7,8,17,27] were performed in Tehran and three studies[15,16,21] in Fars. The characteristics of included studies are presented in Table 1.

Figure 2:
Assessment of the quality of the included articles

Medication errors in intensive care unit nurses

According to the findings, the prevalence of MEs made by ICU nurses was 53.34%[7,8,15–24] [Table 1]. The most common types of MEs made by ICU nurses were wrong infusion rate (14.12%), unauthorized medication (11.76%), and wrong time (8.49%).[7,8,15–22,24] Additionally, MEs occurred more frequently in work shifts of the morning (44.44%), followed by the night (34.71%), and the evening (20.85%).[7,18,19,22] MEs happened more frequently for heparin (12.95%), followed by vancomycin (11.89%), ranitidine (10.84%), amikacin (7.71%), furosemide (6.40%), cefazolin (6.30%), hydrocortisone (6.24%), nitroglycerin (5.93%), metoclopramide (5.33%), midazolam (3.91%), dexamethasone (3.76%), metronidazole (3.47%), clindamycin (3.41%), dopamine (2.45%), phenytoin (2.32%), gentamycin (2.03%), ceftriaxone (2.01%), meropenem (1.53%), and imipenem (1.52%).[7,18,19]

Outcomes associated with medication errors

Bagheri-Nesami et al.[19] assessed the outcomes associated with MEs in patients. In the study, 71% of MEs were not associated with any adverse outcomes. Additionally, 28.2% of MEs led to adverse outcomes such as hypertension, hypotension, nausea, vomiting, tachycardia, bradycardia, flushing, hypoglycemia, hyperglycemia, dysrhythmia, and sedation. Also, 0.8% of MEs led to death due to pancuronium bromide injection without respiratory support.[19]

Factors associated with medication errors

Twelve studies assessed factors associated with MEs made by ICU nurses.[8,15,17,19–27] The researchers classified ME-related factors into the following four categories: (1) management and human factors, (2) environmental factors, (3) drug-related factors, and (4) demographic factors. Details of factors related to MEs in the included studies are presented in Table 2.

Management and human factors

These factors were reported in eight studies.[8,15,19–21,23,26,27] Management and human factors included workload (n = 5), lack of manpower (n = 4), illegibility of doctor’s orders (n = 4), fatigue (n = 3), lack of pharmacological information (n = 3), poor communication between physicians and nurses (n = 2), lack of adequate supervision (n = 2), transcription error (n = 2), managers’ inattention to education (n = 1), insufficient education (n = 1), incorrect medication calculations (n = 1), illiteracy of the nursing Kardex (n = 1), violations of rules (n = 1), memory failure (n = 1), poor communication in the workplace (n = 1), inappropriate drug distribution systems in the hospital (n = 1), multiple prescription changes and inappropriate medical record documentation (n = 1), low access to pharmacological information (n = 1), and work commitment (n = 1).

Environmental factors

These factors were reported in two studies.[25,26] Environmental factors included unsuitable environmental conditions, lack of sufficient equipment, poor lighting, high noise levels, inappropriate room temperature, a high number of patients, lack of appropriate equipment for injection safety, and inadequate space for medication preparation.

Drug-related factors

These factors were reported in three studies.[8,19,20] Drug-related factors included the similarity of drug names (n = 2), similar packaging of drugs (n = 2), a high variety of drugs (n = 1), use of abbreviations (n = 1), use of some drugs in rare cases (n = 1), different drug doses (n = 1), the similar appearance of drugs (n = 1), small instructions on drug packaging (n = 1), receiving incorrect drug doses from a pharmacy (n = 1), incorrect labeling on drugs (n = 1), and lack of access to pharmacists (n = 1).

Demographic factors

These factors were reported in five studies.[17,22–24,26] Demographic factors included work shift (n = 3), age (n = 2), work experience (n = 2), male gender (n = 1), and type of employment (n = 1).


The prevalence of MEs made by Iranian ICU nurses was 53.34%. The most common types of MEs made were wrong infusion rate, unauthorized medication, and wrong time. Additionally, MEs occurred more frequently in the morning, night, and evening work shifts. MEs occurred more frequently for drugs such as heparin, vancomycin, ranitidine, and amikacin. ME-related factors were management and human, environmental, demographic, and drug-related factors.

Somewhat consistent with the present study, the prevalence of MEs in ICU nurses in two studies from Ethiopia[28,29] and one study from South Korea[30] were 51.8%, 40%, and 53.6%, respectively. Inconsistent with the present study, the prevalence of MEs made by ICU nurses in France[31] and Brazil[32] were 6.6% and 7.47%, respectively. These discrepancies may be due to factors such as different definitions of MEs in these studies, different methods for diagnosing MEs, lack of knowledge of ICU nurses about MEs, and differences in the studied populations.[33] However, this study and previous evidence indicate the high prevalence of MEs made in the ICU which remains a global patient safety challenge for critically ill patients.[33–35]

The present study revealed that the most common types of MEs made by Iranian ICU nurses were wrong infusion rate (14.12%), unauthorized use of medications (11.76%), and wrong time (8.49%). Consistent with the present study, the wrong infusion rate in a study in France was the second type of ME made in the ICU (22%).[31] However, in other studies, omission error was one of the most common MEs made in the ICU[28,29,31] which was not one of the most common types of MEs made in Iranian ICUs (4.88%). One of the reasons for this discrepancy may be the lower overall prevalence of MEs in previous studies compared to the present study.

Based on the results of the present study, MEs occurred more frequently in the morning (44.44%), night (34.71%), and evening (20.85%) work shifts. Although assessment of this factor can be effective in prevention of MEs, it has been less considered in previous studies globally. This may be due to differences in medication delivery timing based on different routines, which vary depending on the type of medication, the patient’s condition, and the physician’s prescription pattern. On the other hand, the higher incidence of MEs in the morning shift may be due to the fact that most drugs are prepared and administered in the morning shift. However, some previous studies reported a higher rate of MEs among night shifts nurses, due to fatigue and sleep deprivation.[36]

As shown in the present study, MEs occurred more frequently for drugs such as heparin, vancomycin, ranitidine, and amikacin. Therefore, anticoagulants, antibiotics, and gastrointestinal medications are the most common classes of drugs leading to MEs made in Iranian ICUs. This finding was supported by a study in Ethiopia.[29] However, the results of a study in the United States reported a higher rate of MEs for opioid analgesics (13.2%), β-lactam antibiotics (8.4%), and anticoagulants (6.4%).[37]

In the present study, management and human, environmental, demographic, and drug-related factors were associated with the occurrence of MEs. Consistent with the present study, previous studies[38,39] showed that non-compliance of nurse--to--patient ratio, nurses’ workload and fatigue, insufficient supervision, and managers’ inattention to staff education were the main reasons for the occurrence of MEs. However, human factors are also a major issue in the occurrence of MEs. The results of a study in Australia indicated that the incidence of interruptions in the preparation or administration of drugs in nurses increased the rate of MEs by 12.5%.[40] On the other hand, if the drugs were given without interruption, MEs reduced by 2.3%.[41]

Deficits in pharmacological knowledge and weakness in applying mathematical principles to drug calculations are other important factors in the occurrence of MEs. It is believed that the most important strategy in preventing the occurrence of MEs is ongoing continuing education of nurses in pharmacology, with a focus on drug safety and drug dose calculation.[42]

To minimize MEs, healthcare organizations must institute clear reporting channels and resolve any associated issues such that healthcare workers are able to openly report incidents of MEs without feeling intimidated or worrying about unwarranted punitive measures.[43] Modern technologies such as electronic prescriptions should be instituted across the healthcare system.[44] On the other hand, regular education programs are necessary to keep ICU nurses and other healthcare workers updated with newer drugs and standards.[10]

Although the current study adhered to standard systematic review protocols and presented robust findings, there are some limitations. A meta-analysis was not possible due to difference in the data and tools used in the studies. Also, only one study reported adverse events of MEs.


The prevalence of MEs made by Iranian ICU nurses is high. The most important influential factor in the occurrence of MEs in ICUs was management and human factors. Therefore, nurse managers and policymakers should develop appropriate strategies, including training programs, to reduce the occurrence of MEs made by nurses in ICUs.

Financial support and sponsorship

Mazandaran University of Medical Sciences

Conflicts of interest

Nothing to declare.


The authors of this article thank Mazandaran University of Medical Sciences. The protocol of this study was approved by the institutional ethics committee of Mazandaran University of Medical Sciences (IR.MAZUMS.REC.1399.8597).


1. Classen DC, Munier W, Verzier N, Eldridge N, Hunt D, Metersky M, et al. Measuring patient safety:The Medicare patient safety monitoring system (past, present, and future). J Patient Saf 2021;17:e234–40.
2. Marznaki ZH, Pouy S, Salisu WJ, Emami Zeydi A Medication errors among Iranian emergency nurses:A systematic review. Epidemiol Health 2020;42:e2020030.
3. Organization WH Patient Safety:Making Health Care Safer. World Health Organization 2017.
4. Tully AP, Hammond DA, Li C, Jarrell AS, Kruer RM Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Crit Care Med 2019;47:543–9.
5. Kruer RM, Jarrell AS, Latif A Reducing medication errors in critical care:A multimodal approach. Clin Pharmacol 2014;6:117–26.
6. Suclupe S, Martinez-Zapata MJ, Mancebo J, Font-Vaquer A, Castillo-Masa AM, Viñolas I, et al. Medication errors in prescription and administration in critically ill patients. J Adv Nurs 2020;76:1192–200.
7. Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital:An observational study. Aust Crit Care 2008;21:110–6.
8. Cheraghi MA, Nikbakhat Nasabadi AR, Mohammad Nejad E, Salari A, Ehsani Kouhi Kheyli SR Medication errors among nurses in intensive care units (ICU). J Mazandaran Univ Med Sci 2012;21:115–9.
9. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The Critical Care Safety Study:The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005;33:1694–700.
10. Amiri M, Khademian Z, Nikandish R The effect of nurse empowerment educational program on patient safety culture:A randomized controlled trial. BMC Med Educ 2018;18:1–8.
11. Farokhzadian J, Nayeri ND, Borhani F The long way ahead to achieve an effective patient safety culture:Challenges perceived by nurses. BMC Health Serv Res 2018;18:1–13.
12. Wondmieneh A, Alemu W, Tadele N, Demis A Medication administration errors and contributing factors among nurses:A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nurs 2020;19:1–9.
13. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement:An updated guideline for reporting systematic reviews. BMJ 2021;372:n71.
14. Downes M, Brennan M, Williams H, Dean R Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open 2016;6:e011458.
15. Vazin A, Delfani S Medication errors in an internal intensive care unit of a large teaching hospital:A direct observation study. Acta Med Iran 2012;50:425–32.
16. Vazin A, Fereidooni M Determining frequency of prescription, administration and transcription errors in internal intensive care unit of Shahid Faghihi Hospital in Shiraz with direct observation approach. Iran J Pharm Sci 2012;8:189–94.
17. Fathi A, Rezaei MH, Mohammadi M, Azam K, Barzegar L, Headarnezhad N, et al. Survey of medication error by nurses self-report in intensive care unit of Imam Khomeini hospital-Tehran. Int Res J Appl Basic Sci 2014;8:1726–32.
18. Sohrevardi SM, Mirjalili MR, Jarrahzadeh MH, Mirjalili M, Mirzaei E Evaluating the frequency of errors in preparation and administration of intravenous medications in the intensive care unit of Shahid-Sadoughi hospital in Yazd. J Pharm Care 2014;2:114–9.
19. Bagheri-Nesami M, Esmaeili R, Tajari M Intravenous medication administration errors and their causes in cardiac critical care units in Iran. Mater Socio Med 2015;27:442–6.
20. Dehvan F, Nobahar M, Razavi MR, Ghorbani R Assessment of medication errors and factors affecting its occurrence in intensive critical care units of Semnan city hospitals. J Iran Society Anaesth Intensive Care 2015;37:172–81.
21. Khammarnia M, Sharifian R, Keshtkaran A, Zand F, Barati O, Khonia N, et al. Prescribing errors in two ICU wards in a large teaching hospital in Iran. Int J Risk Saf Med 2015;27:169–75.
22. Sohrevardi SM, Jarahzadeh MH, Mirzaei E, Mirjalili M, Tafti AD, Heydari B Medication errors in patients with enteral feeding tubes in the intensive care unit. J Res Pharm Pract 2017;6:100–5.
23. Farajzadeh M, Ghanei R, Dalvand S, Sarkawt Ghawsi S, Mohammadzadeh M, Reshadi H Medication errors in nurses of Imam Khomeini hospital of Saghez and its related factors. Iran J Rehabil Res 2018;4:10–7.
24. Dashti Z, Mozaffari N, Shamshiri M, Mohammadi M Medication errors and its reporting by nurses of intensive care units of ardabil in 2017. J Health Care 2019;21:184–91.
25. Kaboodmehri R, Hasavari F, Adib M, Khaleghdoost Mohammadi T, Kazemnejhad Leili E Environmental factors contributing to medication errors in intensive care units. J Holist Nurs Midwifery 2019;29:57–64.
26. Bagaei R, Nadari Y, Khalkhali H Evaluation of predisposing factors of nursing errors in critical care units of Urmia Medical Science University hospitals. Nurs Midwifery J? 2012 312–20.
27. Rezaiamin A, Pazokian M, Zagheri Tafreshi M, Nasiri M The relationship between work commitment, dynamic, and medication error. Clin Nurs Res 2017;27:660–74.
28. Agalu A, Ayele Y, Bedada W, Woldie M Medication administration errors in an intensive care unit in Ethiopia. Int Arch Med 2012;5:1–6.
29. Sada O, Melkie A, Shibeshi W Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. BMC Res Notes 2015;8:1–7.
30. Cho I, Park H, Choi YJ, Hwang MH, Bates DW Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One 2014;9:e114243.
31. Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G Medication errors at the administration stage in an intensive care unit. Intensive Care Med 1999;25:353–9.
32. Silva L, Oliveira A, Araújo I, Saldanha V Prescribing errors in an intensive care unit and the role of the pharmacist. Rev Bras Farm Hosp Serv Saude 2012;3:6–10.
33. Assiri GA, Shebl NA, Mahmoud MA, Aloudah N, Grant E, Aljadhey H, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts?A systematic review of the international literature. BMJ Open 2018;8:e019101.
34. Donaldson LJ, Kelley ET, Dhingra-Kumar N, Kieny M-P, Sheikh A Medication without harm:Who's third global patient safety challenge. Lancet 2017;389:1680–1.
35. Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Crit Care Med 2013;41:389–98.
36. Westbrook JI, Raban MZ, Walter SR, Douglas H Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity:A prospective, direct observation study. BMJ Qual Saf 2018;27:655–63.
37. Kane-Gill S, Kowiatek J, Weber R A comparison of voluntarily reported medication errors in intensive care and general care units. BMJ Qual Saf 2010;19:55–9.
38. Wilkins K, Shields M Correlates of medication error in hospitals. Health Rep 2008;19:7–18.
39. Gonzales K Medication administration errors and the pediatric population:A systematic search of the literature. J Pediatr Nurs 2010;25:555–65.
40. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO Association of interruptions with an increased risk and severity of medication administration errors. Arch Int Med 2010;170:683–90.
41. Odom-Forren J Medication administration and errors. J Perianesth Nurs 2010;3:206–7.
42. Cleary-Holdforth J, Leufer T The strategic role of education in the prevention of medication errors in nursing:Part 2. Nurse Educ Pract 2013;13:217–20.
43. Stewart D, Thomas B, MacLure K, Wilbur K, Wilby K, Pallivalapila A, et al. Exploring facilitators and barriers to medication error reporting among healthcare professionals in Qatar using the theoretical domains framework:A mixed-methods approach. PloS One 2018;13:e0204987.
44. Slight SP, Tolley CL, Bates DW, Fraser R, Bigirumurame T, Kasim A, et al. Medication errors and adverse drug events in a UK hospital during the optimisation of electronic prescriptions:A prospective observational study. Lancet Digit Health 2019;1:e403–12.

Intensive care units; Iran; medication errors; nurses; systematic review

Copyright: © 2023 Iranian Journal of Nursing and Midwifery Research