Interventions on Medication Administration Errors in Nigerian and Indonesian Hospitals: A Narrative Review
References
- Institute of Medicine (US) Committee on Quality of Health Care in America. To err is human: building a safer health system [Internet]. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000 [cited 2025 Jan 4]. Available from: https://pubmed.ncbi.nlm.nih.gov/25077248/
- Leape LL, Berwick DM. Five years after to err is human: what have we learned?. JAMA. 2005;293(19):2384-90. https://doi.org/10.1001/jama.293.19.2384
- Grimm CA. Adverse events in hospitals: a quarter of Medicare patients experienced harm in October 2018 [Internet]. Office of Inspector General, I. 2022 [cited 2025 Jan 4];117. Available from: https://collections.nlm.nih.gov/catalog/nlm:nlmuid-9918697339306676-pdf
- World Health Organization. WHO patient safety curriculum guide for medical schools [Internet]. 2009 [cited 2025 Jan 4]. Available from: https://www.who.int/publications/i/item/9789241598316
- World Health Organization. Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care. 2021 [cited 2025 January 4]. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan
- Flott K, Fontana G, Darzi A. The global state of patient safety. London: Imperial College London. 2019 Dec 9 [cited 2025 January 4]. Available from: https://www.pslhub.org/learn/research-data-and-insight/data-and-insight/the-global-state-of-patient-safety-imperial-college-london-2019-r1046/
- Harrison R, Cohen AW, Walton M. Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review. Int J Qual Health Care. 2015;27(4):240-54. Available from: https://www.jstor.org/stable/48518600
- Meyer R, Orser BA, Byrick R. Medication error: a leading cause of anesthesia-related morbidity and mortality. Anesthesiol. 2007;107(6):1033. https://doi.org/10.1097/01.anes.0000290620.54964.96
- Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116-25. https://doi.org/10.1016/j.mayocp.2014.05.007
- Al-Worafi YM. Medication errors. In: Drug safety in developing countries. Academic Press. p. 59-71. https://doi.org/10.1016/C2019-0-00778-9
- Al Tehewy M, Fahim H, Gad NI, El Gafary M, Rahman SA. Medication administration errors in a university hospital. J Patient Saf. 2016;12(1):34-9. https://doi.org/10.1097/PTS.0000000000000196
- Keers RN, Williams SD, Cooke J, Walsh T, Ashcroft DM. Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. Drug Saf. 2014;37:317-32. https://doi.org/10.1007/s40264-014-0152-0
- Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Interventions to reduce nurses’ medication administration errors in inpatient settings: a systematic review and meta-analysis. Int J Nurs Stud. 2016;53:342-50. https://doi.org/10.1016/j.ijnurstu.2015.08.012
- Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review [Internet]. BMJ Qual Saf. 2014;23(5):414-21. Available from: https://qualitysafety.bmj.com/content/23/5/414
- Lapkin S, Levett-Jones T, Chenoweth L, Johnson M. The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews. J Nurs Manag. 2016;24(7):845-58. https://doi.org/10.1111/jonm.12390
- Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf. 2020;11:2042098620968309. https://doi.org/10.1177/2042098620968309
- Nasrin D, Wu Y, Blackwelder WC, Farag TH, Saha D, Sow SO, et al. Health care seeking for childhood diarrhea in developing countries: evidence from seven sites in Africa and Asia. Am J Trop Med Hyg. 2013;89(1):3.
- Molina GG, Ortiz-Juarez E, NETWORK UG. Temporary basic income: protecting poor and vulnerable people in developing countries [Internet]. New York: United Nations Development Programme. 2020 [cited 2025 Jan 4]. Available from: https://www.undp.org/arab-states/publications/temporary-basic-income-protecting-poor-and-vulnerable-people-developing-countries
- Banerjee R, Mishra V, Maruta AA. Energy poverty, health and education outcomes: evidence from the developing world. Energy Econ. 2021;101:105447. https://doi.org/10.1016/j.eneco.2021.105447
- Muzayanah IF, Lean HH, Hartono D, Indraswari KD, Partama R. Population density and energy consumption: a study in Indonesian provinces. Heliyon. 2022;8(9). https://doi.org/10.1016/j.heliyon.2022.e10634
- Hassan Z, Hashim MJ, Khan G. Population risk factors for COVID-19 deaths in Nigeria at subnational level. Pan Afr Med J. 2020;35(2).
- Keers RN, Williams SD, Cooke J, Walsh T, Ashcroft DM. Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. Drug Saf. 2014;37:317-32. https://doi.org/10.1007/s40264-014-0152-0
- Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Interventions to reduce nurses’ medication administration errors in inpatient settings: a systematic review and meta-analysis. Int J Nurs Stud. 2016;53:342-50. https://doi.org/10.1016/j.ijnurstu.2015.08.012
- Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. BMJ Qual Saf. 2014;23(5):414-21.
- Lapkin S, Levett-Jones T, Chenoweth L, Johnson M. The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews. J Nurs Manag. 2016;24(7):845-58. https://doi.org/10.1111/jonm.12390
- Härkänen M, Voutilainen A, Turunen E, Vehviläinen-Julkunen K. Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses. Nurse Educ Today. 2016;41:36-43. https://doi.org/10.1016/j.nedt.2016.03.017
- Berdot S, Vilfaillot A, Bezie Y, Perrin G, Berge M, Corny J, et al. Effectiveness of a ‘do not interrupt’vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nurs. 2021;20(1):153. https://doi.org/10.1186/s12912-021-00671-7
- Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf. 2020 Nov;11:2042098620968309.
- Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook JI. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Qual Saf. 2020;29(7):595-603. https://doi.org/10.1136/bmjqs-2019-009552
- Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. F. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. Joanna Briggs institute reviewer’s manual. JBI; 2017 [cited 2024 Dec 19]. https://doi.org/10.46658/JBIMES-24-06
- Mahendra AD. The natural and prevalence of medication errors in a tertiary hospital in Indonesia. Int Curr Pharm J. 2021;13(3):55-8. https://doi.org/10.22159/ijcpr.2021v13i3.42096
- Musharyanti L, Claramita M, Haryanti F, Dwiprahasto I. Why do nursing students make medication errors? A qualitative study in Indonesia. J. Taibah Univ. Medical Sci. 2019;14(3):282-8. https://doi.org/10.1016/j.jtumed.2019.04.002
- Mulatsih S, Dwiprahasto I, Sutaryo . Implementation of medication safety practice in Childhood Acute Lymphoblastic Leukemia treatment. Asian Pac J Cancer Prev. 2018;19(5):1251-7. https://doi.org/10.22034/APJCP.2018.19.5.1251
- Lumbantobing R, Sauriasari R, Andrajati R. Role of pharmacists in reducing drug-related problems in hemodialysis outpatients. Asian J Pharm Clin Res. 2017;10:108-13. https://doi.org/10.22159/ajpcr.2017.v10s5.23110
- Ernawati DK, Lee YP, Hughes JD. Nature and frequency of medication errors in a geriatric ward: an Indonesian experience. Ther Clin Risk Manag. 2014;10(1):413-21. https://doi.org/10.2147/TCRM.S61687
- Adeleye AO, Oyemolade TA, Malomo TA, Okere OE. Mannitol dosing error during pre-neurosurgical care of head injury: a neurosurgical in-hospital survey from Ibadan, Nigeria. J Neurosci Rural Pract. 2021;12(1):171-6. https://doi.org/10.1055/s-0040-1722093
- Bello CB. Adherence to medication administration guidelines among nurses in a health facility in South-West Nigeria. Pan Afr Med J. 2021;40. Available from: https://www.panafrican-med-journal.com//content/article/40/56/ful
- Ayorinde MO, Alabi PI. Perception and contributing factors to medication administration errors among nurses in Nigeria. Int J Africa Nurs Sci. 2019;11. https://doi.org/10.1016/j.ijans.2019.100153
- Johnson UU, Ebirim LN. Drug errors and protocol for prevention among anaesthetists in Nigeria. Anesthesiol Res Pract. 2017;2017. https://doi.org/10.1155/2017/2045382
- Ilesanmi RE, Okojie EO, Ojerinde AC. Methods of voluntary reporting medication administration errors among nurses in the University College Hospital, Ibadan, Nigeria. Afr J Med Med Sci. 2016;45(2):197-206. https://doi.org/10.1155/2017/2045382
- Nwasor EO, Sule ST, Mshelia DB. Audit of medication errors by anesthetists in North Western Nigeria. Niger J Clin Pract. 2014;17(2):226-31. https://doi.org/10.4103/1119-3077.127563
- Ogboli-Nwasor E. Medication errors in anaesthetic practice: a report of two cases and review of the literature. Afr Health Sci. 2013;13(3):845-9. https://doi.org/10.4314/ahs.v13i3.46
- Al-Worafi Y. Patient safety in developing countries: education, research, case studies. CRC Press; 2023. https://doi.org/10.1201/9781003230465
- Belal AS, AL-Gailani KH, Shady SM, Shima AS, Ruba RR, Bushra NM, et al. Prevalence and associated medication errors in hospitalized pediatric patients in Yemen-across sectional study. Med Sci Acad J-Multidisciplin. 2024;1(1). Available from: https://riyadahpublishers.com/index.php/MSAJM/article/view/8
- Assunção-Costa L, de Sousa IC, Silva RK, do Vale AC, Pinto CR, Machado JF, et al. Observational study on medication administration errors at a University Hospital in Brazil: incidence, nature and associated factors. J Pharm Policy Pract. 2022;15(1):51. https://doi.org/10.1186/s40545-022-00443-x
- Assuncao-Costa L, Costa de Sousa I, Alves de Oliveira MR, Ribeiro Pinto C, Machado JF, Valli CG, et al. Drug administration errors in Latin America: a systematic review. PLoS One. 2022;17(8):e0272123. https://doi.org/10.1371/journal.pone.0272123
- Alemu W, Belachew T, Yimam I. Medication administration errors and contributing factors: a cross sectional study in two public hospitals in Southern Ethiopia. Int J Afr Nurs Sci. 2017;7:68-74. https://doi.org/10.1186/s12912-020-0397-0
- Khalil H, Lee S. The implementation of a successful medication safety program in a primary care. J Eval Clin Pract. 2018;24(2):403-7. https://doi.org/10.1111/jep.12870
- Nahi SA, AL-Zaid MD, Alamri AS, alThabiti MaM, Alshahrani DA, Alsaadi RA. Medication safety practices in healthcare settings: an analysis. JICRCR. 2024:1706-10. Available from: https://powertechjournal.com/index.php/journal/article/view/3001
- Rothschild JM, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55(6):513-21. https://doi.org/10.1016/j.annemergmed.2009.10.012
- Mansur JM. Medication safety systems and the important role of pharmacists. Drugs Aging. 2016;33:213-21. https://doi.org/10.1007/s40266-016-0358-1
- Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69-75. https://doi.org/10.1093/bja/aeq133
- Kiruyi S, Nagadya C, Walusimbi D, Mukooza EK, Higenyi E, Rajab K. Drug and therapeutics committee structure and roles in hospitals: a scoping review. Int J Public Health. 2023 Dec 29. https://doi.org/10.21522/TIJPH.2013.11.04.Art006
- Adhikari R, Tocher J, Smith P, Corcoran J, MacArthur J. A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse Educ Today. 2014;34(2):185-90. https://doi.org/10.1016/j.nedt.2013.10.008
- Wong IC. Improving medication safety and diabetes management in Hong Kong–a multi-disciplinary approach. Hong Kong Med J. 2017;23(2):158-67. https://doi.org/10.12809/hkmj165014
- Bryan R, Aronson JK, Williams A, Jordan S. The problem of look-alike, sound-alike name errors: drivers and solutions. Br J Clin Pharmacol. 2021;87(2):386-94. https://doi.org/10.1111/bcp.14285
- Stewart D, MacLure K, Pallivalapila A, Dijkstra A, Wilbur K, Wilby K, et al. Views and experiences of decision-makers on organisational safety culture and medication errors. Int J Clin Pract. 2020;74(9):e13560. https://doi.org/10.1111/bcp.14285
- Carayon P, Wust K, Hose BZ, Salwei ME. Human factors and ergonomics in health care. Handbook of human factors and ergonomics. 2021:1417-37. https://doi.org/10.1007/978-3-030-59403-9_7
- Sujan M, Pickup L, Bowie P, Hignett S, Ives F, Vosper H, et al. The contribution of human factors and ergonomics to the design and delivery of safe future healthcare. FHJ. 2021;8(3):e574-9. https://doi.org/10.7861/fhj.2021-0112
- Hatem NA, Yousuf SA, Mohamed Ibrahim MI, Al-Galal GS. Insights into participation in ward rounds in hospitals: a survey of clinical pharmacists’ perceptions. J Pharm Policy Pract. 2024;17(1):2285957. https://doi.org/10.1080/20523211.2023.2285957
- Chowdhury TP, Starr R, Brennan M, Knee A, Ehresman M, Velayutham L, et al. A quality improvement initiative to improve medication management in an acute care for elders program through integration of a clinical pharmacist. J Pharm Pract. 2020;33(1):55-62. https://doi.org/10.1177/0897190018786618
- Lee KM, Koeper I, Johnson ME, Page A, Rowett D, Johnson J. Multidisciplinary perspectives on roles of hospital pharmacists in tertiary settings: a qualitative study. Int J Qual Health Care. 2024;36(1):mzad110. https://doi.org/10.1093/intqhc/mzad110
- Hatton K, Bhattacharya D, Scott S, Wright D. Barriers and facilitators to pharmacists integrating into the ward-based multidisciplinary team: a systematic review and meta-synthesis. Res Social Adm Pharm. 2021;17(11):1923-36. https://doi.org/10.1016/j.sapharm.2021.02.006
DOI: https://doi.org/10.15566/kxb1x733 | Journal eISSN: 2167-2415
Language: English
Page range: 168 - 179
Submitted on: Aug 2, 2025
Accepted on: Jan 26, 2026
Published on: Apr 17, 2026
Published by: Global Health Institute at William Carey International University
In partnership with: Paradigm Publishing Services
© 2026 Oyebode Dosunmu, Eliza Dwinta, Fatma Siti Fatimah, published by Global Health Institute at William Carey International University
This work is licensed under the Creative Commons Attribution 4.0 License.