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Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis

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Abstract

Introduction

Neonates are at greater risk of preventable adverse drug events as compared to children and adults.

Objective

This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs).

Methods

A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason’s model of accident causation.

Results

Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4–81.3, I2 = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6–81.1, I2 = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment.

Conclusions

This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

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Acknowledgements

We are thankful to Baptiste Kerouanton for the translation of the papers included and to Dr. Shamin Mohd Saffian for his valuable advice on the meta-analysis performed.

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  1. Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia

    Josephine Henry Basil, Chandini Menon Premakumar, Adliah Mhd Ali, Nurul Ain Mohd Tahir & Noraida Mohamed Shah

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  1. Josephine Henry Basil
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Correspondence to Noraida Mohamed Shah.

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JHB gratefully acknowledges the Ministry of Health Malaysia for funding her PhD programme at the University of Kebangsaan Malaysia. This study received financial support from the Fundamental Research Grants Scheme by the Ministry of Higher Education of Malaysia (FRGS/1/2022/SKK16/UKM/02/7).

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JHB, CMP, AMA, NAMT and NMS declare that they have no conflicts of interest that are directly relevant to the content of this study.

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This research does not contain any studies with human participants or animals performed by any of the authors, and hence, ethics approval is not applicable.

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JHB contributed to the study design, systematic review planning, data extraction, interpretation of data and data analysis and led the article screening, article selection and manuscript writing. NMS and CMP contributed to the study design, data extraction and interpretation of data, article screening, article selection and revision of the manuscript. AMA was involved in the article selection and revision of the manuscript. NAMT was involved in the data extraction and revision of the manuscript. The authors attest that all authors meet authorship criteria and that no authors who meet the criteria have been omitted. All authors have read and approved the final manuscript.

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Henry Basil, J., Premakumar, C.M., Mhd Ali, A. et al. Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis. Drug Saf 45, 1457–1476 (2022). https://doi.org/10.1007/s40264-022-01236-6

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