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APPENDIX E
Appraisal Guide
Findings of a Qualitative Study
Citation:
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_____________________________________________________
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_____________________________________________________
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Synopsis
What experience, situation, or subculture does the researcher
seek to understand?
Does the researcher want to produce a description of an
experience, a social process, or an event, or is the goal to
generate a theory?
How was data collected?
How did the researcher control his or her biases and
preconceptions?
Are specific pieces of data (e.g., direct quotes) and more
generalized statements (themes, theories) included in the
report?
What are the main findings of the study?
Credibility
Is the study published in a source
that required peer review?
Were the methods used appropriate
to the study purpose?
Was the sampling of observations or
interviews appropriate and varied
enough to serve the purpose of the study?
*Were data collection methods
effective in obtaining in-depth data?
clear
Did the data collection methods

avoid the possibility of oversight,
underrepresentation, or
overrepresentation from certain
types of sources?
Were data collection and analysis
intermingled in a dynamic way?
*Is the data presented in ways that
provide a vivid portrayal of what was
experienced or happened and its
context?
*Does the data provided justify
generalized statements, themes,
or theory? t clear
Are the findings credible?
Clinical Significance
*Are the findings rich and informative?
clear
*Is the perspective provided
potentially useful in providing
insight, support, or guidance
for assessing patient status
or progress?
Are the findings
clinically significant?
* = Important criteria
Comments
_____________________________________________________
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_____________________________________________________
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APP E-2 Brown
Brown APP E-1

Shawahna et al. BMC Pediatrics (2022) 22:317
https://doi.org/10.1186/s12887-022-03379-y
RESEARCH
Medication errors in neonatal intensive
care units: a multicenter qualitative study
in the Palestinian practice
Ramzi Shawahna1,2*, Mohammad Jaber3,4*, Rami Said3,
Khalil Mohammad3 and Yahya Aker3
Abstract
Background: Neonatal intensive care units are high-risk settings
where medication errors can occur and cause harm
to this fragile segment of patients. This multicenter qualitative
study was conducted to describe medication errors
that occurred in neonatal intensive care units in Palestine from
the perspectives of healthcare providers.
Methods: This exploratory multicenter qualitative study was
conducted and reported in adherence to the consoli-
dated criteria for reporting qualitative research checklist. Semi-
structured in-depth interviews were conducted with
healthcare professionals (4 pediatricians/neonatologists and 11
intensive care unit nurses) who provided care services
for patients admitted to neonatal intensive care units in
Palestine. An interview schedule guided the semi-structured
in-depth interviews. The qualitative interpretive description
approach was used to thematically analyze the data.
Results: The total duration of the interviews was 282 min. The
healthcare providers described their experiences with
41 different medication errors. These medication errors were
categorized under 3 categories and 10 subcategories.
Errors that occurred while preparing/diluting/storing

medications were related to calculations, using a wrong solvent/
diluent, dilution errors, failure to adhere to guidelines while
preparing the medication, failure to adhere to storage/
packaging guidelines, and failure to adhere to labeling
guidelines. Errors that occurred while prescribing/administer-
ing medications were related to inappropriate medication for the
neonate, using a different administration technique
from the one that was intended, and administering a different
dose from the one that was intended. Errors that
occurred after administering the medications were related to
failure to adhere to monitoring guidelines.
Conclusion: In this multicenter study,
pediatricians/neonatologists and neonatal intensive care unit
nurses described
medication errors occurring in intensive care units in Palestine.
Medication errors occurred in different stages of the
medication process: preparation/dilution/storage,
prescription/administration, and monitoring. Further studies are
still
needed to quantify medication errors occurring in the neonatal
intensive care units and investigate if the designed
strategies could be effective in minimizing the medication
errors.
Keywords: Medication errors, Newborn, Neonatal intensive care
unit, Qualitative analysis
© The Author(s) 2022. Open Access This article is licensed
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line to the data.
Introduction
Improving the safety of patients in hospitals is a top pri-
ority in all healthcare systems around the world. Reports
from different parts of the world have shown that medica-
tion errors continue to jeopardize the safety and health of
hospital inpatients [1–4]. Medication errors often receive
attention from government officials, policymakers in
Open Access
*Correspondence: [email protected]; [email protected]
edu; [email protected]
1 Department of Physiology, Pharmacology and Toxicology,
Faculty
of Medicine and Health Sciences, An-Najah National
University, Nablus,
Palestine
3 Department of Medicine, Faculty of Medicine and Health
Sciences, An-

Najah National University, Nablus, Palestine
Full list of author information is available at the end of the
article
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
http://creativecommons.org/publicdomain/zero/1.0/
http://crossmark.crossref.org/dialog/?doi=10.1186/s12887-022-
03379-y&domain=pdf
Page 2 of 11Shawahna et al. BMC Pediatrics (2022)
22:317
healthcare, professional associations, patient advocacy
groups, and the general public. Neonatal intensive care
units are high-risk settings where medication errors can
occur and cause harm to this fragile segment of patients
[3]. Neonates in intensive care units are particularly vul-
nerable to medication errors because of their immaturity,
small body size, need for laborious error-prone dose cal-
culations or dilutions, the severity of their disease condi-
tion, and intensity of medications used [3, 5, 6].
In Palestine, patients receive healthcare from 3 main
providers: the government, non-governmental organi-
zations, the United Nations Relief and Works Agency
for Palestine Refugees in the Near East (UNRWA), and
the private sector. Across the country, there are approxi-
mately 234 beds in the neonatal intensive care units (192
beds in the West Bank and 42 beds in the Gaza Strip).
A recent study reported that governmental and non-
governmental hospitals in Palestine suffered shortages
in incubators, ventilators, humidifiers, and ward space
were also reported [7]. Additionally, shortages in neo-
natal nurses, neonatologists, and pediatricians with sub-

specialties were also reported [7–9]. In the absence of
adequate nurse-to-patient ratios, providers of healthcare
services in the neonatal intensive care units are often
overwhelmed with their daily workloads. Moreover,
healthcare providers in hospitals often report receiving
insufficient guidelines and training relevant to the safe
prescribing, preparation, administration, and monitoring
of medications [10–13]. Together, these working condi-
tions increase the likelihood of medication errors in neo-
natal intensive care units. Although medication error
incidence reports are available, healthcare providers
described the reporting and surveillance system as inef-
fective [10, 12]. In the current practice, healthcare pro-
viders file a medication error incident report themselves
in case of a confirmed medication error that caused seri-
ous harm to the patient. Medication errors that did not
cause serious harm and near-misses are seldom reported.
In neonatal intensive care units, medications are often
prescribed by the attending pediatrician/neontologist.
Medications are almost always prepared and adminis-
tered by the neonatal intensive care unit nurses. Due to
shortages of staff, double-check standards for medication
preparation and administration are not routinely used
in the neonatal intensive care units. Medication errors
can occur at any stage in the medication process such as
preparation/dilution, packaging, prescribing, dispens-
ing, administration, and monitoring [6]. Previous studies
have shown that medication errors occurred in neona-
tal intensive care units in Qatar, Iran, Saudi Arabia, and
Brazil [1, 6, 14, 15]. A recent systematic review reported
medication error rates in the range of 4 to 35.1 per 1,000
patient-days in neonatal intensive care units and from
5.5 to 77.9 per 100 medication orders [3]. Dosing errors
were the most commonly reported medication errors

in neonatal intensive care units. Of all medical errors
reported in neonatal intensive care units, medication
errors accounted for 47.2% of all errors [16]. Medication
errors that cause harm to the patients are eightfold more
likely to occur in neonatal intensive care units compared
to those occurring in adult intensive care units [5].
It is noteworthy mentioning that the majority of the
studies that reported on medication errors in neonatal
intensive care units were quantitative in nature. There-
fore, medication error situations have not been described
in sufficient details. Qualitative research methods are
commonly used as powerful tools in describing com-
plex phenomena, shedding light on the experiences of
the study participants, exploring views of key actors and
stakeholders in certain phenomena, developing new the-
ories, and seeking interpretations [17, 18]. Additionally,
qualitative and quantitative approaches can be used in
sequence, tandem, and/or can be complementary to each
other.
Little was reported on the incidence of medication
errors in neonatal intensive care units in Palestine and
medication errors have not been described before. In a
previous study, the safety culture in different neonatal
intensive care units in Palestine was described as subop-
timal [8]. Understanding medication errors occurring in
neonatal intensive care units might help design strate-
gies to minimize these errors and improve the safety of
patients and healthcare delivery in neonatal intensive
care units. Therefore, this multicenter qualitative study
aimed to describe medication errors that occurred in
neonatal intensive care units in Palestine from the per-
spectives of healthcare providers.
Methods

Study design
This exploratory multicenter qualitative study was con-
ducted and reported in adherence to the consolidated
criteria for reporting qualitative research (COREQ)
checklist. Adherence to the COREQ checklist is provided
in Supplementary Table S1. Semi-structured in-depth
interviews were conducted with healthcare profession-
als who provided care services for patients admitted
to 4 main neonatal intensive care units in Palestine. An
interview schedule guided the semi-structured in-depth
interviews.
Sample size and sampling method
In this qualitative study, thematic saturation was used to
determine the endpoint of the interviews. Informed by
previous qualitative studies that were conducted with
healthcare providers, thematic saturation was expected
22:317
to be achieved in about 5 h of interview time [13, 19–21].
Assuming an average interview duration of 30 min, inter-
views with 10 healthcare providers were expected to
achieve thematic saturation in this study.
A purposive sampling technique was used to identify,
invite, and recruit the interviewees. Personal contacts
in the field were used to approach and invite the poten-
tial interviewees who were pediatricians/neonatologists
and intensive care unit nurses who were the providers of
care services to patients admitted to the 4 main neona-
tal intensive care units in Palestine. The healthcare pro-
viders were invited and recruited when they satisfied the

following inclusion criteria: 1) being licensed to practice
medicine or nursing in Palestine, 2) practicing in a hos-
pitalized patient setting in Palestine, 3) providing direct
care using medications in a neonatal intensive care unit
in Palestine, and 4) having at least 5 years of practical
experience in a neonatal intensive care unit in Palestine.
Healthcare providers who did not meet the inclusion
criteria and those who did not agree to participate in a
recorded qualitative interview were excluded from this
study.
Data collection
The healthcare providers were interviewed by three
male 6th-year medical students (RS, KM, YA) who were
trained to conduct semi-structured in-depth inter-
views by the principal investigator (RS) who had exten-
sive experience in conducting interviews and qualitative
studies. Throughout their clinical training, the three stu-
dents received formal and supervised training on how
to conduct interviews and communicate with patients,
nurses, physicians, and other healthcare providers. The
interviews in this study were conducted with the help
of an interview schedule that was developed specifically
for this study. The interview schedule was developed to
contain open-ended questions to allow the interview-
ees to provide an elaborated description of the medica-
tion errors. The interviewers also used prompts to clarify
answers and descriptions provided by the healthcare pro-
viders during the interviews. The interview guide was
reviewed by 5 healthcare providers to ensure face validity
and ability of the questions to collect adequate descrip-
tions of medication errors. The reviewers were asked to
rate each question for clarity, relevance, and suitability
on a scale of 1–5 (1 = not clear/relevant/suitable at all,
5 = very clear/relevant/suitable). The questions that were
rated as clear/relevant/suitable or very clear/relevant/

suitable were included in the interview guide. Conflicting
views were discussed and resolved through consensus.
The healthcare providers were interviewed in a quiet
place in the hospitals. The interview guide collected the
sociodemographic and practice characteristics of the
healthcare providers like gender, specialty, type of hos-
pital, and number of years in practice. The interviewees
were asked to self-report the approximate number of
neonatal patients they care for per shift. The interview-
ees were also asked to provide an approximate number of
patients admitted to each neonatal intensive care unit per
month and reasons for admission of patients to the neo-
natal intensive care unit. The interviewees were asked to
indicate if a functional system for reporting medication
errors and near-misses existed in the neonatal intensive
care units, if they believed that neonatal intensive care
units were high-risk settings, if they believed medication
errors in neonatal intensive care units were more likely
compared to adult settings, and to provide reasons why
they believed so. The healthcare providers were then
asked to describe medication errors they experienced in
the neonatal intensive care units. The interview guide is
provided in Supplementary Table S2. The interviews were
audio-recorded and the interviewers took field notes.
Data analysis
All recordings were transcribed verbatim before analy-
sis. The qualitative interpretive description approach
was used to thematically analyze the data [22–25]. The
qualitative interpretive description approach is power-
ful in promoting the recognition of categories and sub-
categories in cases that involve diverse and complex
experiences such as medication errors [26]. Additionally,
the Leuven Qualitative Analysis Guide was used to help

identify categories and subcategories [27]. The research-
ers independently read and familiarized themselves with
the transcripts (the transcripts were read 34 times). The
researchers independently identified the important state-
ments, formulated their meanings, and clustered them
into major categories. The researchers met and devel-
oped a detailed description of the major categories and
subcategories, and condensed the medication errors
into the major categories and subcategories. Finally, the
researchers verified if all medication errors were accu-
rately captured and categorized under the major catego-
ries and subcategories. To protect participant identity,
who could may have made the medication error, nurses,
physicians, or any other healthcare provider were coded
as “a healthcare provider”.
Bracketing was used to maintain the trustworthiness
and credibility of the analysis. Throughout the study,
the researchers made all efforts to keep their personal,
knowledge, experiences, and expectations aside to avoid
any preconception bias [28, 29]. To ensure dependabil-
ity, the researchers kept and reviewed audit trails of the
analytical decisions. Repeated readings of the transcripts,
regular discussion between the researchers, consensus
to solve conflicting decisions, and triangulation of the
22:317
qualitative data from each interview script were used to
ensure accurate sorting of the error situations into the
major categories and subcategories [30].
HE

All aspects of the study protocol and ethics were
approved by the Institutional Review Board (IRB) of An-
Najah National University. Approvals were also obtained
from the administration, ethics, and/or research commit-
tees of the 4 hospitals. The study was conducted in adher-
ence to the principles of scientific and medical research
included in the Declaration of Helsinki. All participants
provided written informed consent before they took part
in this study.
Results
Fifteen healthcare providers participated in the inter-
views. The total duration of the interviews was 282 min
(range: 15–25 min).
Characteristics of the interviewees
Of the interviewees, 4 (26.7%) were pediatricians/neo-
natologists and 11 (73.3%) were neonatal intensive care
nurses. For the pediatricians/neonatologists, the median
number of years in practice was 22.5 (20.5, 25.8) years
and the median number of years in practice for the neo-
natal intensive care nurses was 11 (8.5, 12.5) years. The
median number of neonatal patients care for by the
pediatricians/neonatologists per day was 14.5 (13.0, 15.8)
patients and the median number of neonatal patients
care for by the nurses per day was 6.0 (6.0, 7.0) patients.
Of the interviewees, 10 (66.7%) were employed by gov-
ernmental hospitals. The characteristics of the inter-
viewees stratified by the type of hospital are provided in
Table 1.
Characteristics of the patients admitted to the neonatal
intensive care units
The interviewees stated that there were about 250 to 300
new admissions to each neonatal intensive care unit per
month. The majority of the patients admitted to the neo-

natal intensive care units were preterm or extremely pre-
term with low or very low birth bodyweight. The other
common reasons for admission included preterm neo-
nates who developed hyaline membrane disease/acute
respiratory distress syndrome, transient tachypnea of the
newborn, sepsis, congenital diaphragmatic hernia, and/
or jaundice.
Experiences of the interviewees with medication errors
in the neonatal intensive care unit
The interviewees stated that not all neonatal inten-
sive care units have a functional system for reporting
medication errors and near-misses. One of the interview-
ees stated:
“…a fully functional system for reporting medication
errors and near-misses does not exist in our neona-
tal intensive care unit. We might file an incidence
report when a medication error caused a serious
harm to the patient.”
The healthcare providers who were interviewed in this
study agreed that neonatal intensive care units were high-
risk settings and medication errors were more likely com-
pared to adult settings because of the need for laborious
error-prone medication dose calculations/dilutions. The
healthcare providers also stated that neonates were more
vulnerable to harm from medication errors compared to
adults because of their immaturity, small body size, and
disease conditions. One of the interviewees stated:
“…..there is no doubt that medication errors are
more likely in neonatal intensive care settings.
Patients are immature, have a small body size, and
are fragile.”

In this study, the healthcare providers described expe-
riencing 41 different medication errors. These medica-
tion errors were categorized under 3 main categories and
10 subcategories.
Errors that occurred while preparing/diluting/storing
a medication
In this study, the interviewees described 24 medication
errors that occurred while preparing/diluting/storing
medications. Of those 24 errors, 3 (12.5%) were related
to calculations, 3 (12.5%) were related to using a wrong
Table 1 Characteristics of the interviewees (n = 15)
Characteristic Type of hospital
Governmental Private
Gender
Male 5 3
Female 5 2
Profession
Pediatrician/neonatologist 3 1
Neonatal intensive care nurse 7 4
Number of years in practice
< 10 3 2
≥ 10 7 3
Self-reported approximate number of neonatal patients care for
per shift

< 8 5 1
≥ 8 5 4
22:317
solvent/diluent, 3 (12.5%) were dilution errors, 6 (25.0%)
were related to failure to adhere to guidelines while pre-
paring a medication, 4 (16.7%) were related to failure to
adhere to storage/packaging guidelines, and 5 (20.8%)
were related to failure to adhere to labeling guidelines.
Details of these medication errors are shown in Table 1.
Errors that occurred while prescribing/administering
a medication
The interviewees described 15 medication errors that
occurred while prescribing/administering a medication.
Of those errors, 5 were related to inappropriate medica-
tion for the neonate, 5 were related to a different admin-
istration technique from the one that was intended, and
5 were related to a different dose from the one that was
intended. Details of these medication errors are shown in
Table 2.
Errors that occurred after administering a medication
(monitoring errors)
The interviewees described 2 monitoring error incidents
that occurred after administering medications. These
errors were related to failure to adhere to monitoring
guidelines. Details of these medication errors are shown
in Table 2.

Discussion
Medication errors in neonatal intensive care units can
result in significant harm to this subsegment of frag-
ile patients. This multicenter qualitative study was con-
ducted to describe medication errors in 4 main neonatal
intensive care units in Palestine. To the best of our knowl-
edge, this is the first description of medication errors that
occurred in neonatal intensive care units in Palestine. A
total of 41 different medication errors were described by
the healthcare providers. The findings of this study could
be informative to policymakers in healthcare authorities,
professional organizations, patient advocacy groups, and
other stakeholders who might need to take action and
design strategies to minimize medication errors in neo-
natal intensive care units.
Preterm/extremely preterm with low/very low birth
bodyweight, development of hyaline membrane disease/
acute respiratory distress syndrome, transient tachypnea
of the newborn, sepsis, congenital diaphragmatic hernia,
and/or jaundice were the common reasons for admitting
neonates to the neonatal intensive care units in Palestine.
These findings were consistent with those reported on
the common reasons for admitting neonates to neona-
tal intensive care units elsewhere [31, 32]. Although the
majority of the healthcare providers considered neonatal
intensive care units as high-risk settings, a functional sys-
tem for reporting medication errors and near-misses was
not present in all neonatal intensive care units in Pales-
tine. It is universally accepted that reporting medication
errors and near-misses is of great importance [33]. It has
been argued that quantitative, as well as qualitative analy-
sis of root causes of medication errors, can aid in design-
ing strategies to minimize these errors [34, 35]. The
findings of this study may add to the existing literature by

providing a qualitative description of medication errors
by healthcare providers who experienced these medica-
tion errors.
In this study, the healthcare providers described medi-
cation errors that occurred while preparing/diluting/
storing, prescribing/administering, and monitoring
administered medications. The findings of this qualitative
study were consistent with those that previously reported
medication errors during the different stages of the
medication process [6, 36]. Because of their small body
size, doses of medications for neonates often need to be
individualized. This would often require laborious error-
prone dose calculations/dilutions which may result in
overdoses that lead to toxicity or underdoses that may
prolong the stay of the neonate in the intensive care unit
[3, 5, 6, 34]. Overdoses and subtherapeutic doses of some
medications can lead to serious adverse effects, delay
recovery, increase the length of hospitalization, and/
or even can result in the death of the patients [37, 38].
Review of the dose calculations, preparation, dilution,
and administration steps by a second healthcare provider
(double-check) and using a computerized program to cal-
culate the individualized doses might reduce calculation
errors [38]. Using the wrong solvent/diluent and failure to
adhere to guidelines while preparing the medication were
reported by the healthcare providers in this study. The
findings of this study were consistent with those reported
in previous studies in neonatal intensive care units [3, 5,
6, 36]. The use of look-alike ampoules/vials and lack of
adherence to basic preparation guidelines increased the
incidence of medication errors. Manufacturers need to
consider distinguishing ampoules/vials using distinct
colors/sizes/shapes/designs and policymakers/manag-
ers should consider training/educating healthcare pro-
viders on the importance of adhering to the preparation

guidelines. These measures might reduce the incidence
of these errors in neonatal intensive care units [5, 39].
Moreover, the production of age-appropriate dosage
units for neonates by the pharmaceutical industry can
reduce the need for extemporaneous preparation/dilu-
tion of medications for this segment of patients and, thus,
can reduce the incidence of these medication errors [40].
In this study, the healthcare providers reported that fail-
ure to adhere to storage/packaging guidelines resulted in
medication errors in the neonatal intensive care units.
The findings of this study indicated that healthcare
22:317
Table 2 Summary of the medication errors that occurred in
neonatal intensive care units that were experienced by the
interviewees
# Category Medication errors
Errors that occurred while preparing/diluting/storing a
medication
1 Calculation errors A healthcare provider failed to correctly
calculate a dose of a medica-
tion for a neonate and the final preparation contained an
overdose/
underdose
2 A healthcare provider failed to verify an ambiguous
medication
preparation order and prepared a dose of a medication for a
neonate

using cubic centimeters (cc)/milliliters (mL) when milligrams
(mg) were
intended
3 A healthcare provider failed to verify the correct weight of the
neonate
and calculated a dose of a medication based on an incorrect
weight. The
dose resulted in an overdose/underdose
4 Using a wrong solvent/diluent A healthcare provider failed to
adhere to the preparation guidelines and
used the wrong solvent instead of distilled water while
preparing a dose
of potassium chloride for a neonate
5 A healthcare provider withdrew sodium bicarbonate instead of
amino
acids from a look-alike ampule while preparing a dose for a
neonate
6 A healthcare provider failed to adhere to the preparation
guidelines
and used normal saline instead of dextrose while preparing a
dose of
ertapenem for a neonate
7 Dilution errors A healthcare provider failed to adhere to the
preparation guidelines
and diluted a dose of adrenaline that was intended for
endotracheal
administration for a neonate
guidelines and
did not dilute an intravenous dose of aminophylline that was

intended
for a neonate
guidelines and
used an excessive amount of the diluent which resulted in a
subthera-
peutic dose that was intended for a neonate
10 Failure to adhere to guidelines while preparing a medication
A healthcare provider failed to check the expiry dates of the
ingredients
used to prepare a dose of a medication that was intended for a
neonate
11 A healthcare provider failed to check a broken vial/ampoule
that con-
tained pieces of glass before using it in preparing a dose of a
medication
that was intended for a neonate
12 A healthcare provider failed to adhere to the guidelines and
did not
use different syringes and needles while preparing doses of
different
medications that were intended for neonates
prepared a
dose of medication that required strict aseptic techniques in a
contami-
nated area
did not
completely dissolve the ingredients leaving precipitates in an

intrave-
nous preparation that was intended for a neonate
15 A healthcare provider failed to calibrate the balance used to
prepare a
dose of a medication for a neonate and the final preparation
contained
an overdose/underdose
16 Failure to adhere to storage/packaging guidelines A
healthcare provider failed to adhere to the storage guidelines for
a
light-sensitive medication and the medication was exposed to
light for a
significantly long time
17 A healthcare provider failed to adhere to the storage
guidelines and
stored a medication in a humid environment while the
instructions
dictated that the medication should be stored in a dry place
18 A healthcare provider failed to adhere to the storage
guidelines and
stored a medication at room temperature while the instructions
dictated
that the medication should be stored in a refrigerator
packed
doses of two different medications using identical packages
22:317

Table 2 (continued)
20 Failure to adhere to labeling guidelines A healthcare
provider failed to adhere to the guidelines and did label a
prepared dose of the medication with the name of the neonate as
in the
wristband
did label a
prepared dose of the medication with the name of the
medication
did label a
prepared dose of the medication with the dose
did label
the dose of the medication with the route of administration
did label a
prepared dose of the medication with the date of
preparation/expiry
Errors that occurred while prescribing/administering a
medication
1 The prescribed/administered medication was not appropriate
for the
neonate
A healthcare provider failed to check the wristband of a neonate

and
administered a dose of a medication that was intended for
another
neonate
2 A healthcare provider did not verify the expiry date of the
medication
and administered a dose of an expired medication to a neonate
3 A healthcare provider failed to check the patient’s allergy
notes and pre-
scribed/administered a dose of vancomycin when the notes
indicated
that the neonate had an allergy to vancomycin
4 A healthcare provider administered two medications for a
neonate that
were known to have a significant drug-drug interaction
medication order
and administered a different medication for a neonate from the
one that
was intended (e.g., ibuprofen when paracetamol/acetaminophen
was
intended)
6 The administration technique was different from the one that
was
intended
A healthcare provider failed to verify an ambiguous medication
order
and administered a dose of a medication for a neonate using a
route
of administration that was different from the one that was

intended
(e.g., intravenous prednisolone when inhaled was intended, oral
when
intravenous was intended, and intramuscular when intravenous
was
intended)
7 A healthcare provider failed to adhere to the administration
guidelines
and administered a dose of a medication for a neonate using
rapid
intravenous push when the instructions dictated that the dose
had to
be administered slowly over a longer period (e.g., fentanyl,
potassium
chloride, and gentamycin)
8 A healthcare provider failed to insert the cannula correctly
and adminis-
tered a dose of a medication that is known to cause
extravasation (e.g.,
total parenteral nutrition, potassium, calcium, bicarbonate, and
high
concentration dextrose)
9 A healthcare provider failed to adhere to the administration
instructions
and administered a dose of a medication for a neonate over a
shorter/
longer period from the one that was intended (e.g.,
administration for
10 min when administration for 30 min was intended)
10 A healthcare provider failed to verify if the cannula was
open and started
administering the medication while the cannula was closed

of 11Shawahna et al. BMC Pediatrics (2022)
22:317
providers need to be trained/educated on the importance
of adherence to storage/packaging guidelines to reduce
the incidence of these errors [35, 39]. Mislabeling was
also reported by the healthcare providers who were inter-
viewed in this study. Complete and accurate labels of pre-
pared medications are important to avoid confusion and
situations leading to harmful medication errors [10, 11,
35]. In this study, 15 prescription/administration medi-
cation errors were reported by the healthcare providers.
Error situations were related to prescribing/administer-
ing an inappropriate medication to the patient, using an
erroneous administration technique, or a wrong dose.
These situations were formally considered medication
errors that needed to be eliminated by panels of health-
care providers [12]. Some medications need to be moni-
tored following administration. Adequate monitoring
can reduce the incidence of adverse effects that can be
associated with these medications. In this study, lack of
adequate monitoring resulted in harmful adverse effects.
These findings were consistent with those that reported
harmful medication errors among patients admitted to
neonatal intensive care units [3, 6, 16].
Decision-makers in healthcare authorities and other
stakeholders should consider designing strategies to min-
imize medication errors occurring in neonatal intensive
care units and improve the health outcomes of neonates.
These interventions might include educational and train-
ing sessions to improve awareness, adherence to guide-
lines, and numeracy skills of the healthcare providers in

neonatal intensive care units [5, 39, 41, 42]. Additionally,
the use of computers, robots, bar-codes, double-check
standards, improving storage layout, and labeling of vials/
ampoules might also help minimize medication errors
that occur while preparing/diluting/storing the medi-
cation in neonatal intensive care units [16]. It has been
suggested that using age-appropriate pre-filled and pre-
labeled doses can eliminate the need for the preparation
or dilution of medication doses [40, 43]. This would ulti-
mately minimize medication errors. Employing a clinical
pharmacist as a member of the healthcare team might
minimize medication errors in the neonatal intensive
care units [44, 45]. Clinical pharmacists are experts in
medications and can help optimize doses of medications,
monitor their effects, and screen for adverse effects.
Strengths and limitations of the study
This multicenter explorative study had several strengths.
In this study, medication errors in neonatal intensive
care units were reported for the first time. Understand-
ing these medication errors can help stakeholders design
appropriate measures to minimize these errors. Second,
the healthcare providers who were interviewed in this
study were providers of care services in the main neona-
tal intensive care units in Palestine. Multicenter recruit-
ment of the healthcare providers should have allowed
a description of the main medication error situations
that occurred in these centers. Third, although pedia-
tricians/neonatologists were included, the majority of
Table 2 (continued)
11 The administered dose was different from the one that was

intended A healthcare provider failed to adhere to the
prescription/administration
instructions and forgot to administer the medication to the
neonate
medication order for
a neonate and administered a dose of 10 mg morphine when 1
mg was
intended
medication order
for a neonate and administered the medication at a frequency
that was
different from the one that was intended (e.g., every 3 h instead
of every
6 h or every 6 h instead of every 3 h)
14 A healthcare provider failed to program the intended
infusion rate on an
infusor or used the infusion rate that was programmed for the
previous
medication
15 A healthcare provider failed to adhere to the
prescription/administration
instructions and administered the calculated maintenance dose
instead
of the loading dose for a neonate
Errors that occurred after administering a medication
(monitoring errors)
1 Failure to adhere to monitoring guidelines A healthcare
provider failed to adhere to the monitoring guidelines and

failed to monitor renal function after a dose of a medication that
caused
nephrotoxicity in a neonate (e.g., vancomycin)
2 A healthcare provider failed to adhere to the monitoring
guidelines and
failed to monitor heart rate after administering a dose of a
medication
to a neonate that caused cardiac arrhythmias (e.g., calcium
gluconate,
potassium chloride, and fentanyl)
22:317
the healthcare providers who were interviewed in this
study were intensive care unit nurses. Recruitment of
nurses was purposive because intensive care unit nurses
provide the majority of healthcare services to neonates
admitted to these units. The healthcare services pro-
vided by intensive care unit nurses include calculation
of doses, preparation/dilution of medications, adminis-
tration of medications, monitoring therapeutic effects,
and screening for adverse effects. Fourth, the interview-
ees were diversified in terms of gender, specialty, type of
hospital, length of practical experience, and the number
of neonates cared for. This diversity should have added
strength and rigor to the qualitative data generated in
this study.
On the other hand, the findings of this multicenter
study should be interpreted considering some limita-
tions. First, a qualitative approach was used in this
study. Qualitative data are merely opinions and views

of the interviewees. Although qualitative approaches
are powerful in describing medication errors, a quan-
titative approach by counting the number of errors in
each error category should have added another dimen-
sion to the findings of this study. In this study, we could
have attempted to quantify the medication errors that
occurred in neonatal intensive care units. However, in
the absence of an effective error reporting and surveil-
lance systems, direct observation would be the only alter-
native. Second, data generated in a qualitative are prone
to bias by the opinions of the interviewers. Although bias
cannot be completely ruled out, audio recordings of the
interviews, bracketing, reviews of audit trails, repeated
readings of the transcripts, regular discussion between
the researchers, using consensus to solve conflict-
ing decisions, and triangulation of the qualitative data
should have improved rigor, trustworthiness, and cred-
ibility of the data generated in this study. Third, parents/
legal guardians of neonates were not interviewed in this
study. Identifying parents/legal guardians of neonates
who have experienced medication errors could have
ensured the inclusion of their description of their expe-
rience with medication errors in neonatal intensive care
units. Finally, we did not classify the medication errors
based on the severity of their outcomes or harm caused
to the patient. Such classification should have been more
informative. Future studies should consider categorizing
medication error situations by the harm caused to the
patient.
Conclusion
In this multicenter study, pediatricians/neonatologists
and neonatal intensive care unit nurses described medica-
tion errors occurring in intensive care units in Palestine.
Medication errors occurred in different stages of the medi-

cation process: preparation/dilution/storage, prescription/
administration, and monitoring. Further studies are still
needed to quantify medication errors occurring in the neo-
natal intensive care units and investigate if the designed
strategies could be effective in minimizing the medication
errors.
Supplementary Information
The online version contains supplementary material available at
https:// doi.
org/ 10. 1186/ s12887- 022- 03379-y.
Additional file 1: Supplementary Table S1. Adherence to
COnsolidated
criteriafor REporting Qualitative research (COREQ)Checklist
[1]. Supple-
mentary Table S2. Interview guide.
Acknowledgements
The authors would like to thank the healthcare providers who
participated in
the study. An-Najah National University is acknowledged for
making this study
possible.
Authors’ contributions
R Shawahna and MJ were involved in the conception and design
of the
work, analysis and interpretation of data, drafting, and final
approval of the
manuscript. R Said, KM, and YA were involved in the data
acquisition, analysis,
drafting of the work and final approval of the version to be
published. “The
author(s) read and approved the final manuscript.”

Funding
The costs of the transcription, formal translation, and thematic
analysis were
covered by the Deanship of Scientific Research, An-Najah
National University
through the project number (ANNU-2021-Sc010) of the 4th call
of the Dean-
ship of Scientific Research projects.
Availability of data and materials
All data analyzed during this study are included in the results
section of this
manuscript and the supplementary materials.
Declarations
Ethics approval and consent to participate
All aspects of the study protocol and ethics were approved by
the Institu-
tional Review Board (IRB) of An-Najah National University.
Approvals were also
obtained from the administration, ethics, and/or research
committees of the 4
hospitals. The study was conducted in adherence to the
principles of scientific
and medical research included in the Declaration of Helsinki.
All participants
provided written informed consent before they took part in this
study.
Consent for publication
Not applicable.
Competing interests
All authors report no competing interests.

Author details
1 Department of Physiology, Pharmacology and Toxicology,
Faculty of Medi-
cine and Health Sciences, An-Najah National University,
Nablus, Palestine.
2 An-Najah BioSciences Unit, Centre for Poisons Control,
Chemical and Biologi-
cal Analyses, An-Najah National University, Nablus, Palestine.
3 Department
of Medicine, Faculty of Medicine and Health Sciences, An-
Najah National
University, Nablus, Palestine. 4 An-Najah National University
Hospital, Nablus,
Palestine.
Received: 28 January 2022 Accepted: 24 May 2022
https://doi.org/10.1186/s12887-022-03379-y
https://doi.org/10.1186/s12887-022-03379-y
22:317
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Medication errors in neonatal intensive care units: a multicenter
qualitative study in the Palestinian practiceAbstract
Background: Methods: Results: Conclusion:
IntroductionMethodsStudy designSample size and sampling
methodData collectionData analysisHEResultsCharacteristics
of the intervieweesCharacteristics of the patients admitted
to the neonatal intensive care unitsExperiences
of the interviewees with medication errors in the neonatal
intensive care unitErrors that occurred
while preparingdilutingstoring a medicationErrors that occurred

while prescribingadministering a medicationErrors that occurred
after administering a medication (monitoring
errors)DiscussionStrengths and limitations
of the studyConclusionAcknowledgementsReferences
APPENDIX C
Appraisal Guide
Conclusions of a Systematic Review with Narrative Synthesis
Citation:
_____________________________________________________
_______________________
_____________________________________________________
_______________________
_____________________________________________________
_______________________
Synopsis
What organization or persons produced the systematic review
(SR)?
How many persons were involved in conducting the review?
What topic or question did the SR address?
How were potential research reports identified?
What determined if a study was included in the analysis?
How many studies were included in the review?
What research designs were used in the studies?
What were the consistent and important across-studies
conclusions?
Credibility
Was the topic clearly defined?
Was the search for studies and other
evidence comprehensive and unbiased?
clear
Was the screening of citations for
inclusion based on explicit criteria?
*Were the included studies assessed
for quality?
Were the design characteristics and

findings of the included studies displayed
or discussed in sufficient detail?
*Was there a true integration (i.e., synthesis) of the findings—
not
merely reporting of findings from
each study individually?
*Did the reviewers explore why differences
in findings might have occurred?
Did the reviewers distinguish between
conclusions based on consistent findings
from several good studies and those
based on inferior evidence (number or quality)?
No ar
Which conclusions were supported by
consistent findings from two or more
good or high-quality studies? List
_____________________________________________________
_______________________
_____________________________________________________
_______________________
_____________________________________________________
_______________________
Are the conclusions
credible?
Clinical Significance
*Across studies, is the size of the
treatment or the strength of the
association found or the
meaningfulness of qualitative findings
strong enough to make a difference
in patient outcomes or experiences of care?
Are the conclusions relevant to the
care the nurse gives?
Are the conclusions
clinically significant?

Applicability
Does the SR address a problem,
situation, or decision we are addressing in our setting?
Are the patients in the studies or a
subgroup of patients in the studies
similar to those we see?
What changes, additions, training, or
purchases would be needed to implement
and sustain a clinical protocol based
on these conclusions? Specify and list
_____________________________________________________
_______________________
_____________________________________________________
_______________________
Is what we will have to do to implement
the new protocol realistically achievable
by us (resources, capability, commitment)?
How will we know if our patients are
benefiting from our new protocol? Specify
_____________________________________________________
_______________________
_____________________________________________________
_______________________
Are these conclusions
applicable to our setting?
Should we proceed to design
a protocol incorporating
these conclusions?
* = Important criteria
Comments
_____________________________________________________
_______________________
_____________________________________________________
_______________________

APP C-2 Brown
Brown APP C-1
PHARMACOEPIDEMIOLOGY AND PRESCRIPTION
Medication errors in hospitals in the Middle East: a systematic
review
of prevalence, nature, severity and contributory factors
Binny Thomas1,2 & Vibhu Paudyal3 & Katie MacLure4
& Abdulrouf Pallivalapila1 & James McLay5 & Wessam El
Kassem1
&
Moza Al Hail1 & Derek Stewart6
Received: 8 December 2018 /Accepted: 2 May 2019 /Published
online: 24 May 2019
# The Author(s) 2019
Abstract
Purpose The aim was to critically appraise, synthesise and
present the evidence of medication errors amongst hospitalised
patients in Middle Eastern countries, specifically prevalence,
nature, severity and contributory factors.
Methods CINAHL, Embase, Medline, Pubmed and Science
Direct were searched for studies published in English from 2000
to
March 2018, with no exclusions. Study selection, quality
assessment (using adapted STROBE checklists) and data
extraction
were conducted independently by two reviewers. A narrative
approach to data synthesis was adopted; data related to error

causation were synthesised according to Reason’s Accident
Causation model.
Results Searching yielded 452 articles, which were reduced to
50 following removal of duplicates and screening of titles,
abstracts and full-papers. Studies were largely from Iran, Saudi
Arabia, Egypt and Jordan. Thirty-two studies quantified errors;
definitions of ‘medication error’were inconsistent as were
approaches to data collection, severity assessment, outcome
measures
and analysis. Of 13 studies reporting medication errors per
‘total number of medication orders’/ ‘number of prescriptions’,
the
median across all studies was 10% (IQR 2–35). Twenty-four
studies reported contributory factors leading to errors. Synthesis
according to Reason’s model identified the most common being
active failures, largely slips (10 studies); lapses (9) and
mistakes
(12); error-provoking conditions, particularly lack of knowledge
(13) and insufficient staffing levels (13) and latent conditions,
commonly heavy workload (9).
Conclusion There is a need to improve the quality and reporting
of studies from Middle Eastern countries. A standardised
approach to quantifying medication errors’ prevalence, severity,
outcomes and contributory factors is warranted.
Keywords Medication errors . Prescribing errors . Error
causation . Systematic review .Middle East
Introduction
In 1999, the ‘Institute of Medicine’ (now the National
Academy of Medicine) published the seminal report ‘To Err
Is Human: Building a Safer Health System’ quantifying the
scale of harm associated withmedical care in the United States
(US) [1]. The authors called for coordinated efforts by gov-
ernments, healthcare providers and consumers and others to

promote patient safety, setting a minimum goal of 50% reduc-
tion in medical errors by 2004. Despite global advances in
healthcare practices, an estimated one in ten patients is still
harmed while receiving care [2]. In March 2017, the World
Health Organization (WHO) published ‘Medication Without
Harm, WHO Global Patient Safety Challenge’ [3, 4]. It called
for action to reduce patient harm which occurs as a result of
unsafe medication practices and medication errors. The aim is
to ‘gain worldwide commitment and action to reduce severe,
avoidable medication-related harm by 50% in the next 5 years,
Electronic supplementary material The online version of this
article
(https://doi.org/10.1007/s00228-019-02689-y) contains
supplementary
material, which is available to authorized users.
* Derek Stewart
[email protected]
1 Medication Safety and Quality Center, Pharmacy Executive
Office,
Hamad Medical Corporation, PO Box 3050, Doha, Qatar
2 School of Pharmacy and Life Sciences, Robert Gordon
University,
Aberdeen AB10 7JG, UK
3 School of Pharmacy, University of Birmingham, Birmingham
B15
2TT, UK
4 School of Pharmacy and Life Sciences, Robert Gordon
University,
Aberdeen AB10 7JG, UK
5 The Institute of Applied Health Sciences, University of

Aberdeen,
Aberdeen AB25 2ZD, UK
6 College of Pharmacy, Qatar University, Doha PO Box 2713,
Qatar
European Journal of Clinical Pharmacology (2019) 75:1269–
1282
https://doi.org/10.1007/s00228-019-02689-y
http://crossmark.crossref.org/dialog/?doi=10.1007/s00228-019-
02689-y&domain=pdf
http://orcid.org/0000-0001-7360-8592
https://doi.org/10.1007/s00228-019-02689-y
mailto:[email protected]
specifically by addressing harm resulting from medication
errors or unsafe practices due to weaknesses in healthcare
systems’. One key objective is to ‘assess the scope and nature
of avoidable harm and strengthen the monitoring systems to
detect and track this harm’ [3, 4].
A number of published systematic reviews have attempted
to quantify medication errors at various stages of the medica-
tion use processes of prescribing, transcribing, verifying, ad-
ministration, dispensing and monitoring [5–21]. These have
largely focused on secondary care inpatients, with most
reporting errors committed in targeted groups of patients in-
cluding paediatrics, acute care, older people, mental health
and perioperative care. Many of these reviews also reported
data on contributory factors leading to errors [6, 9–11, 14, 17,
21]. One key limitation highlighted in many of these reviews
is the lack of a standardised approach to defining and measur-
ing errors, limiting the validity of any pooling of data from
different studies and different systematic reviews.

Furthermore, the very different healthcare structures and pro-
cesses across the world may limit the generalisability of find-
ings to other contexts. Given the first objective of the WHO
challenge, there may be merit in conducting systematic re-
views capturing studies from specific contexts to provide the
most meaningful data which can be used to inform future
strategies and interventions.
Given the differing healthcare systems, ethnicity, culture
and work practices of the Middle East, there may be merit in
conducting systematic reviews of studies within that geo-
graphical area (i.e. Bahrain, Egypt, Iran, Iraq, Israel, Jordan,
Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia,
Syria, Turkey, United Arab Emirates and Yemen). In 2013,
Alsulami et al. published a systematic review of studies up to
and including 2011 on the incidence and types of medication
errors in Middle Eastern countries and main contributory fac-
tors [10]. While noting that error rates were difficult to com-
pare between studies due to being expressed differently, pre-
scribing errors ranged from 7.1% of prescriptions in a teaching
hospital to 90.5% of prescriptions in a primary healthcare
centre. Poor knowledge of medicines was identified as a con-
tributory factor for errors by doctors and nurses.
One limitation of this reviewwas the lack of any theories of
error causation in the synthesis stage. Incorporation of theory
in primary studies or systematic reviews will yield findings
which provide more comprehensive coverage of the key in-
fluential factors. The most commonly used and cited theoret-
ical framework in this field is Reason’s Accident Causation
model. This model groups error causes as follows:
1. Active failures which are unsafe acts committed by people
who are in direct contact with the patient or system. They
take a variety of forms including slips and lapses (errors in
task execution), mistakes (errors in planning) and proce-

dural violations (rule breaking).
2. Error-producing conditions which can have adverse ef-
fects of error-provoking conditions within the local work-
place (e.g. time pressure, understaffing, inadequate equip-
ment, fatigue and inexperience).
3. Latent failures which arise from decisions made by policy
makers, leaders and top-level management [22].
Furthermore, the review highlighted that published papers
from Middle Eastern countries were relatively few and gener-
ally of poor quality. Given the advances in healthcare in recent
years, an updated systematic review incorporating error theory
is warranted.
The aim of this systematic reviewwas to critically appraise,
synthesise and present the available evidence of medication
errors amongst hospitalised patients in Middle Eastern coun-
tries, specifically prevalence, nature, severity and contributory
factors.
Methods
The systematic review protocol was developed in accordance
with the Preferred Reporting Items for Systematic Review and
Meta-Analysis Protocols (PRISMA-P) guidelines [23] and
registered with the International Prospective Register of
Systematic Reviews (PROSPERO, CRD42015019693) [24].
Inclusion and exclusion criteria
Primary research studies of any design conducted in hospital
settings in the Middle East (as defined in the introduction)
which quantified medication errors (i.e. prescribing, adminis-
tration or dispensing errors) published as full papers in

English from 2000 to the end of March 2018 were included
in the review. Studies which reported error nature, severity or
associated causative factors were also included. Studies of
adverse drug events which were not classified as errors were
excluded, as were review articles, letters, opinion papers, ed-
itorials and conference abstracts.
Search strategy
The search was conducted in Cumulative Index of Nursing
and Cumulative Allied Health Literature (CINAHL), Embase,
Medline, Pubmed and Science Direct. Search terms (title, ab-
stract, text, keyword) were (medic* OR prescrib* OR
dispens* OR administ*) AND (error* OR incident* OR mis-
take*) AND (Middle East OR Bahrain OR Egypt OR Iran OR
Iraq OR Israel OR Jordan ORKuwait OR Lebanon OROman
OR Palestine OR Qatar OR Saudi Arabia OR Syria OR
Turkey OR United Arab Emirates ORYemen). The reference
lists of all identified papers were reviewed to identify addi-
tional studies.
1270 Eur J Clin Pharmacol (2019) 75:1269–1282
Screening
Screening of titles (BT, DS), abstracts (BT, DS) and full pa-
pers (BT, DS) was independently performed by two re-
viewers, with disagreements resolved by consensus and re-
ferred to a third reviewer (KM) whenever required.
Assessment of methodological quality
Papers were independently assessed for methodological qual-
ity by two reviewers (BT and one of DS, VP, AP, JM, WEK,

MAH)with disagreements resolved by consensus and referred
to a third reviewer whenever required. The STROBE checklist
(STrengthening the Reporting of OBservational studies in
Epidemiology) was adapted as a quality assessment tool
[25]. For all study designs, STROBE criteria retained were
those relating to bias with addition of criteria specific to med-
ication errors (e.g. error definitions). For qualitative studies,
credibility and dependability replaced validity and reliability,
and transferability replaced generalisability.
Data extraction
A bespoke data extraction tool was developed and piloted to
extract the following: authors, country of publication/study,
year of publication, study population, setting, recruitment, er-
ror quantification, nature of errors, error severity and contrib-
utory factors. Data extraction was also performed by two in-
dependent reviewers, as per quality assessment.
Data synthesis
Previous systematic reviews have highlighted the heterogene-
ity of studies in terms of error definitions, methods of mea-
surement and outcome measures [5–21]; hence, a narrative
approach to data synthesis was selected a-priori. Data related
to error causation were synthesised using Reason’s Accident
Causation model as a theoretical framework in terms of active
failures, error-producing conditions and latent failures [22].
Results
Study screening
Database searching and review of reference lists yielded 452
articles, 110 of which were duplicates and excluded. Review
of titles and abstracts excluded 213 papers with full-paper

review excluding a further 79. Fifty papers were included in
the quality assessment stage. The PRIMSA flowchart is given
in Fig. 1. Of the fifty studies, 48 were of a quantitative, cross-
sectional design and two were qualitative in nature.
Quality assessment
Of the 50 studies, none met all 11 STROBE-related quality
assessment criteria. Thirteen studies (26%) met eight or more
criteria, 21 (42%) between five and seven criteria and the
remaining 16 (32%) meeting four or less. Key limitations
centred on lack of justification for the method of sampling
and sample size, and not adequately considering issues of data
validity and reliability (quantitative studies) and trustworthi-
ness (qualitative studies). Supplementary Table 1 gives the
findings of the quality assessment processes.
Characteristics of included studies
Almost half of the studies were conducted in Iran (n = 23,
46%), followed by Saudi Arabia (n = 10, 20%), Egypt and
Jordan (n = 5 each, 10%), Turkey (n = 2, 4%) and one each
(2%) from Israel, Qatar, Yemen, Palestine and Lebanon. None
of the studies reported data from more than one country. Two
thirds (n = 33, 66%) were conducted in university-affiliated or
academic hospitals, one fifth (n = 10, 20%) tertiary care non-
teaching hospitals and only three (6%) in general hospitals.
Three studies (6%) did not state the type of hospital and one
(2%) reported an analysis of a national online database.
Within each hospital, a range of specific patient groups was
targeted, mostly adults, and the most common types of wards
chosen were intensive care units.
The definition of medication errors (or sub-categories of
medication errors) was inconsistent. In the 50 studies, 17 dif-
ferent definitions were given, differing in wording and con-

tent. The most widely used was that of the US National
Coordinating Council for Medication Error Reporting and
Prevention (NCCMERP) [26]. Ten studies (20%) adopted
non-standardised definitions from previous studies or provid-
ed their own definition. Three studies (6%) used the definition
of medication errors as per Aronson et al. [27]. Two studies
(4%) on prescribing errors used the definition of the American
Society of Health-System Pharmacists [28]. One study each
used definitions provided by Dean et al. [29] and the Institute
of Medicine [30]. Twelve studies (24%) did not provide any
definition of either medication errors or the sub-category be-
ing reported.
Quantifying medication errors
Of the 32 studies quantifying medication errors, the most
common methods of data collection were via review of med-
ication charts or records (prescribing, dispensing and admin-
istration) (n = 11, 31%) or by analysis of data from an error or
incident monitoring system (n = 9, 28%). Only one study
employed multiple approaches to data collection. Data collec-
tion periods ranged from 20 days to 2 years. Data extraction of
the 32 studies is provided in Supplementary Table 2.
Eur J Clin Pharmacol (2019) 75:1269–1282 1271
Inconsistencies in definitions of ‘medication error’, ‘prescrib-
ing error’ etc., together with the vast range of approaches to
data collection and presentation of findings, limited pooling of
data hence a narrative approach to data synthesis was
employed. Almost half of the studies (n = 32, 47%) quantified
‘medication errors’ in general, with fewer solely reporting
‘administration errors’ (n = 7, 22%) or ‘prescribing errors’
(n = 6, 18%) and one (3%) reporting only transcribing errors.

Three studies reported data with combinations of classifica-
tions of medication errors.
The specific terms used in the studies to report medications
errors varied and eight different denominators were used, the
most frequent being ‘total number of medication orders’ or
‘number of prescriptions’ (n = 13, 40%), followed by ‘number
of patients admitted’ (n = 6, 19%) and ‘total number of oppor-
tunities for errors’ (n = 4, 12%). One study (3%) each used
‘total number of preparations’, ‘total number of medications
dispensed’, ‘total number of cases/records’, ‘total number of
patient days’ and ‘total number of reports’. Four studies (13%)
did not specify the denominator.
Given this marked heterogeneity, it was not possible to
make valid comparisons of the outcome measure of preva-
lence. Even in studies which used the same outcome measure,
the error definitions and methods of measurement varied con-
siderably. The following results should therefore be
interpreted with caution.
Of the 13 studies reporting medication errors per ‘total
number of medication orders’/‘number of prescriptions’, the
median across all studies was 10% (IQR 2–35%). The rates
varied from 0.18 to 56 per 100 medication orders’/‘number of
prescriptions’. Of the six studies reporting ‘number of patients
admitted’, the median was 28% (IQR 1–35%), varying from
0.15 to 40 errors per 100 patient admissions.
Nature and severity of medication errors
Almost all studies (31/32, 97%) provided data regarding the
nature of the errors. For prescribing errors, the most common-
ly reported included errors of omission, wrong drug, wrong
dose, wrong route, incomplete order, wrong duration, drug-

Fig. 1 PRISMA flowchart
describing systematic review
search and study selection
drug interaction and wrong patient. Studies reporting admin-
istration errors were largely related to wrong administration
time, wrong administration route and wrong infusion rate.
Fourteen studies (43%) reported the specific medications
most commonly associated with errors. Most frequently re-
ported therapeutic groups included anti-infectives for systemic
use, drugs used for alimentary tract and metabolism and car-
diovascular drugs.
Thirteen studies (40%) reported error severity, with eight
categorising according to the NCCMERP Index [26]. These
studies, however, provided very little methodological detail on
the application of the index, specifically assessment of inter-
rater reliability. In five studies, the most common category
was B (near miss), with C (error occurred and reached the
patient but with no harm) in two studies and E (error occurred
and may have contributed to or resulted in temporary harm
and required intervention) in one study.
Contributory factors
Twenty-four studies (48%) from six Middle-Eastern countries
reported causes or contributory factors leading to medication
errors. Approaches to data collection were largely based on
questionnaires (15/24, 63%), data from incident reporting sys-
tems (n = 4, 17%), direct observation of practice (n = 2, 8%),
semi-structured interviews (n = 2, 8%) and retrieval of infor-

mation from patient medical records (n = 1, 4%). A total of
3919 health professionals were involved in these 24 different
studies. Notably, none of these 24 studies used any theory (e.g.
behavioural, organisational) in the processes of data collection
or analysis. As described in the methods section, findings
from these 24 studies were categorised according to
Reason’s Accident Causation model [22] (Table 1), and syn-
thesis of the categories is provided in Table 2. Contributory
factors most commonly reported were active failures, largely
slips, lapses and mistakes; error-provoking conditions, partic-
ularly those relating to lack of knowledge and insufficient
staffing levels and latent conditions, most commonly heavy
workload. Error-provoking conditions such as lack of experi-
ence, poor documentation and look-alike drugs, or latent con-
ditions of issues relating to a blame culture were rarely
reported.
Discussion
Statement of key findings
Heterogeneity in medication error definitions and scope, dif-
ferences in methods of data collection and units of analysis of
the studies included in this review limited data pooling. Most
frequently reported was the percentage of medication errors
per total number of medication orders with a median across all
studies of 10% (IQR 2–35%). Prescribing errors were the
most common type of errors reported, with dose-related errors
being most prevalent. Contributory factors associated with
medication errors were multifactorial. Synthesis of findings
according to Reason’s Accident Causation model identified
that active failures (slips, lapses andmistakes) weremost com-
monly reported followed by error-provoking conditions (e.g.
lack of knowledge, insufficient staffing), with latent failures
(e.g. heavy workload) least reported.

Strengths and weaknesses
There are several strengths to this review. The protocol was
developed according to the standards of PRISMA-P
(Preferred Reporting Items for Systematic review and Meta-
Analysis Protocols [23], registered in the PROSPERO data-
base [24], and the systematic review reported according to
PRISMA (Preferred Reporting Items for Systematic Review
and Meta-Analysis) criteria [55]. The synthesis adopted a
theory-driven approach based on Reason’s Accident
Causation Model [22], which could subsequently facilitate
the development of interventions. There are, however, several
weaknesses; hence, the review findings should be interpreted
with caution. Restricting the search to the English language
and excluding those written in regional languages of Arabic or
Persian may have limited retrieval of potentially relevant stud-
ies. It is, however, worth noting that English is the preferred
language of most professional organisations in the Middle
East.
Interpretation of key findings
Although there has been an increase in the number of medi-
cation errors studies originating fromMiddle East over the last
few years, two thirds were from Iran and Saudi Arabia with
none from eight countries. While the reasons for the lack of
studies in other countries are unknown, this does have impli-
cations for the generalisability and transferability of review
findings and conclusions. Furthermore, there was a lack of
studies employing a qualitative approach to explore contribu-
tory factors of errors.
The majority of studies had key limitations in study design
and lacked transparency in reporting key study details.
Authors should be encouraged to adopt standardised reporting

checklists available from the EQUATOR (Enhancing the
QUAlity and Transparency Of health Research) network
[56]. This international network aims to ‘improve the reliabil-
ity and value of published health research literature by pro-
moting transparent and accurate reporting.’ An example is the
STROBE checklist (Strengthening the Reporting of
Observational Studies in Epidemiology) for reporting obser-
vational studies [25].
Ta
bl
e
1
C
la
ss
if
ic
at
io
n
of
m
ed
ic
at
io
n
er
ro

r
co
nt
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fa
ct
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s
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ut
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r(
s)
,y
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co
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et
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do
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tti

ng
,p
ar
tic
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ts
,
nu
m
be
r
C
la
ss
if
ic
at
io
n
of
co
nt
ri
bu
to
ry
fa
ct
or
s
as

pe
r
R
ea
so
n’
s
A
cc
id
en
tC
au
sa
tio
n
m
od
el
[2
2]
A
bd
ar
et
al
.2
01
4,
Ir

an
[3
1]
C
ro
ss
-s
ec
tio
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ls
ur
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y
Se
tti
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—
4
ac
ad
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sp
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rt
ic

ip
an
ts
—
nu
rs
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N
o.
of
pa
rt
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—
23
8
E
rr
or
-p
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du
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co
nd
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on
s

•
In
su
ff
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ie
nt
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af
f
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se
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tig
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•

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ad
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19
0
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•
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•
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ap
se
—
fa
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d
to
pu
tc
or
re
ct

la
be
ls
on
m
ed
ic
at
io
ns
•
M
is
ta
ke
—
de
liv
er
ed
in
co
rr
ec
tm
ed
ic
at
io
n

do
se
s
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
Ph
ys
ic
ia
ns
’
m
ed
ic
at
io
n
or
de
rs

ill
eg
ib
le
•
M
an
y
pa
tie
nt
s
re
ce
iv
in
g
si
m
ila
r
m
ed
ic
at
io
ns
•
L
im
ite
d
kn

ow
le
dg
e
of
m
ed
ic
at
io
ns
L
at
en
tF
ai
lu
re
s
•
po
or
co
m
m
un
ic
at
io
n

•
L
im
ite
d
ac
ce
ss
to
m
ed
ic
at
io
n
in
fo
rm
at
io
n.
•
M
ed
ic
at
io
n
ex
pe
rt

s
no
ta
va
ila
bl
e.
C
he
ra
gi
et
al
.
20
13
,
Ir
an
[3
8]
C
ro
ss
-s
ec
tio
na
ls

ur
ve
y
Se
tti
ng
—
ac
ad
em
ic
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
23

7
A
ct
iv
e
fa
ilu
re
s
•
Sl
ip
s—
w
ro
ng
pa
tie
nt
,
•
L
ap
se
—
fa
ilu
re
to

gi
ve
m
ed
ic
at
io
n
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•L
ar
ge
va
ri
et
y
of
dr
ug

s
in
th
e
m
ed
ic
at
io
n
ca
bi
ne
t•
So
un
d
al
ik
e
m
ed
ic
at
io
ns
•
To
o
bu
sy
an

d
tir
ed
fr
om
ex
ce
ss
iv
e
w
or
k
(n
ur
se
s)
L
at
en
tF
ai
lu
re
s
•
la
ck
of

tr
ai
ni
ng
•
la
ck
of
st
af
fi
ng
T
ab
le
1
(c
on
tin
ue
d)
A
ut
ho
r(

s)
,y
ea
r,
co
un
tr
y
M
et
ho
do
lo
gy
Se
tti
ng
,p
ar
tic
ip
an
ts
,
nu
m
be
r
C
la
ss

if
ic
at
io
n
of
co
nt
ri
bu
to
ry
fa
ct
or
s
as
pe
r
R
ea
so
n’
s
A
cc
id
en
tC
au
sa
tio

n
m
od
el
[2
2]
•
M
is
ta
ke
—
pr
es
cr
ib
in
g
w
ro
ng
do
sa
ge
an
d
in
fu
si
on

ra
te
•
V
io
la
tio
n—
us
in
g
ac
ro
ny
m
s
of
m
ed
ic
at
io
n
na
m
es
D
ib
bi
,e
ta

l.
20
06
,
Sa
ud
iA
ra
bi
a
[3
9]
R
et
ro
sp
ec
tiv
e
ch
ar
t
re
vi
ew
Se
tti
ng
—

ge
ne
ra
lh
os
pi
ta
l
Pa
rt
ic
ip
an
ts
—
no
t
re
le
va
nt
N
o.
of
pa
rt
ic
ip
an
ts
-2

62
7
A
ct
iv
e
fa
ilu
re
s
•
Sl
ip
s—
ch
oo
si
ng
w
ro
ng
m
ed
ic
at
io
n
(l
oo

k
al
ik
e
an
d
so
un
d
al
ik
e)
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
L
ac
k
of
kn
ow

le
dg
e
•
Pe
rf
or
m
an
ce
de
fi
ci
t
E
hs
an
ie
t
al
.2
01
3,
Ir
an
[4
0]
C
ro

ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng
—
ac
ad
em
ic
ho
sp
ita
l
Pa
rt
ic
ip
an
ts
—
nu
rs
es

N
o.
of
pa
rt
ic
ip
an
ts
—
94
A
ct
iv
e
fa
ilu
re
s
•
Sl
ip
s—
ch
oo
si
ng
w
ro
ng

m
ed
ic
at
io
n
(l
oo
k
al
ik
e
an
d
so
un
d
al
ik
e)
•
V
io
la
tio
n—
us
in
g
ab
br

ev
ia
te
d
na
m
es
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
Fa
tig
ue
fr
om
ha
rd
w
or

k•
Il
le
gi
bi
lit
y
•
In
su
ff
ic
ie
nt
ph
ar
m
ac
ol
og
ic
al
kn
ow
le
dg
e
L
at
en
tf

ai
lu
re
s
•
H
ig
h
pa
tie
nt
-t
o-
nu
rs
e
ra
tio
•
In
su
ff
ic
ie
nt
ed
uc
at
io
n/
tr

ai
ni
ng
Fa
rz
ie
t
al
.2
01
7,
Ir
an
[4
1]
Se
m
i-
st
ru
ct
ur
ed
in
di
vi
du
al
in
te
rv

ie
w
s
Se
tti
ng
—
ac
ad
em
ic
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
ph
ys
ic
ia
ns
,
nu
rs
es

an
d
cl
in
ic
al
ph
ar
m
ac
is
ts
N
o.
of
pa
rt
ic
ip
an
ts
—
19
A
ct
iv
e
fa
ilu
re
s

•
Sl
ip
s—
lo
ok
al
ik
e,
so
un
d
al
ik
e
•
M
is
ta
ke
—
in
co
m
pl
et
e
m
ed
ic

at
io
n
or
de
rs
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
L
ac
k
of
kn
ow
le
dg
e
of

he
al
th
ca
re
te
am
•
L
ac
k
of
pr
of
es
si
on
al
co
m
m
un
ic
at
io
n
•
L
ac
k
of

m
ed
ic
at
io
n
re
co
nc
ili
at
io
n
•
In
te
rr
up
tio
n/
ta
lk
in
g
w
hi
le
m
ed
ic
at
io
n
ad

m
in
is
tr
at
io
n
•
L
ac
k
of
ph
ar
m
ac
eu
tic
al
kn
ow
le
dg
e
L
at
en
tf
ai
lu
re
s

•
L
ac
k
of
m
on
ito
ri
ng
or
su
pe
rv
is
or
y
m
ec
ha
ni
sm
s
•
W
ea
k
pr
of
es
si

on
al
co
lla
bo
ra
tio
n
be
tw
ee
n
he
al
th
ca
re
te
am
•
L
ac
k
of
m
an
ag
em
en
td

ec
is
io
ns
•
L
ac
k
of
ad
eq
ua
te
st
af
fi
ng
Fa
th
ie
t
al
.2
01
7,
Ir
an
[4
2]

C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng
—
7
ac
ad
em
ic
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu

rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
50
0
A
ct
iv
e
Fa
ilu
re
s
•
Sl
ip
s—
lo
ok
al

ik
e,
so
un
d
al
ik
e
•
M
is
ta
ke
—
w
ro
ng
la
be
lli
ng
E
rr
or
-p
ro
du
ci
ng
co
nd

iti
on
s
•
In
ap
pr
op
ri
at
e
be
ha
vi
or
of
pa
tie
nt
s
•
Fa
tig
ue
fr
om
ha
rd
w
or

k
•
Ph
on
e
ca
ll
or
de
rs
•
H
ig
h
nu
m
be
r
of
pa
tie
nt
s
•
N
oi
sy
en
vi
ro

nm
en
t
L
at
en
tf
ai
lu
re
s
•
L
ac
k
of
m
on
ito
ri
ng
or
su
pe
rv
is
or
y
m
ec
ha

ni
sm
s
•
Sh
or
ta
ge
of
nu
rs
in
g
st
af
f
•
L
ac
k
of
dr
ug
in
fo
rm
at
io
n

re
so
ur
ce
s
G
or
gi
ch
et
al
.
20
16
,I
ra
n
55
]
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y

Se
tti
ng
—
ac
ad
em
ic
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—

32
7
A
ct
iv
e
fa
ilu
re
s
•
V
io
la
tio
n—
un
re
ad
ab
le
or
de
rs
E
rr
or
-p
ro
du

ci
ng
co
nd
iti
on
s
•
Fa
tig
ue
du
e
to
hi
gh
w
or
kl
oa
d
•
L
ar
ge
nu
m
be
r

of
cr
iti
ca
lly
ill
pa
tie
nt
s
•
Po
or
ph
ys
ic
al
en
vi
ro
nm
en
t(
lig
ht
,t
em
pe
ra
tu

re
)
•
Po
or
co
m
m
un
ic
at
io
n
be
tw
ee
n
te
am
m
em
be
rs
L
at
en
tf
ai
lu
re
s

•
L
ow
ra
tio
of
nu
rs
es
to
pa
tie
nt
s
•
Fa
ilu
re
in
em
ph
as
is
in
g
th
e
im

po
rt
an
ce
of
re
co
rd
in
g
an
d
re
po
rt
in
g
th
e
m
ed
ic
at
io
n
er
ro
rs
•
B
la
m
e
cu

ltu
re
G
ün
eş
et
al
.2
01
4,
T
ur
ke
y
[4
3]
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng

—
2
go
ve
rn
m
en
t
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—

24
3
A
ct
iv
e
fa
ilu
re
s
•
L
ap
se
—
ph
ys
ic
ia
ns
no
tw
ri
tin
g
dr
ug
ro
ut
e

•
M
is
ta
ke
—
pr
es
cr
ib
in
g
in
te
ra
ct
in
g
dr
ug
s
•
V
io
la
tio
n—
ph
ys
ic
ia
ns

no
tw
ri
tin
g
th
e
or
de
r
or
no
ti
n
tim
e
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•

In
te
rr
up
tio
n
by
te
le
ph
on
e
et
c.
w
hi
le
pr
ep
ar
in
g
m
ed
ic
at
io
n
•
Po
or
m

at
he
m
at
ic
al
sk
ill
s
fo
rd
ru
g
do
se
ca
lc
ul
at
io
n
H
am
m
ou
di
et
al
.
20

17
,S
au
di
A
ra
bi
a
[4
4]
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng
—
te
rt
ia
ry
ca

re
ho
sp
ita
l
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
36
7
E
rr
or
-p

ro
du
ci
ng
co
nd
iti
on
s
•
Il
le
gi
bi
lit
y
of
pa
tie
nt
s’
re
co
rd
s
•
W
ro
ng
m
ed

ic
at
io
n
pr
ep
ar
at
io
n
by
ph
ar
m
ac
is
ts
L
at
en
tf
ai
lu
re
s
L
ow
st
af
fi
ng

M
ra
yy
an
et
al
.
20
07
,J
or
da
n
[4
5]
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng
—

11
go
ve
rn
m
en
t
an
d
11
pr
iv
at
e
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.

of
pa
rt
ic
ip
an
ts
—
79
9
A
ct
iv
e
fa
ilu
re
s
•
Sl
ip
s—
nu
rs
es
co
nf
us
ed

by
di
ff
er
en
tt
yp
es
an
d
fu
nc
tio
ns
of
in
fu
si
on
de
vi
ce
s
•
L
ap
se
—
nu
rs
e
fa

ils
to
ch
ec
k
th
e
pa
tie
nt
na
m
e
w
ith
m
ed
ic
at
io
n
ad
m
in
is
tr
at
io
n
re
co
rd

E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
N
ur
se
s
di
st
ra
ct
ed
by
ot
he
r
pa
tie
nt
s,
co
-w

or
ke
rs
or
ev
en
ts
on
un
it
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
A
ct
iv
e
fa
ilu
re
s

E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
T
ab
le
1
(c
on
tin
ue
d)
A
ut
ho

r(
s)
,y
ea
r,
co
un
tr
y
M
et
ho
do
lo
gy
Se
tti
ng
,p
ar
tic
ip
an
ts
,
nu
m
be
r
C
la

ss
if
ic
at
io
n
of
co
nt
ri
bu
to
ry
fa
ct
or
s
as
pe
r
R
ea
so
n’
s
A
cc
id
en
tC
au
sa

tio
n
m
od
el
[2
2]
M
ra
yy
an
et
al
.
20
12
,J
or
da
n
[4
6]
Se
tti
ng
—
ac
ad
em

ic
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
21
2
•
M
is
ta
ke

—
in
ac
cu
ra
te
ra
te
of
to
ta
lp
ar
en
te
ra
ln
ut
ri
tio
n
•
Po
or
qu
al
ity
or
da
m

ag
ed
m
ed
ic
at
io
n
la
be
ls
•
Fe
ar
of
di
sc
ip
lin
ar
y
ac
tio
ns
Pa
w
lu
k
et
al
.

20
17
,Q
at
ar
[3
5]
R
et
ro
sp
ec
tiv
e
an
al
ys
is
fr
om
in
ci
de
nt
re
po
rt
in
g

sy
st
em
Se
tti
ng
—
te
rt
ia
ry
ca
re
ho
sp
ita
l
Pa
rt
ic
ip
an
ts
—
no
t
re
le
va
nt

N
o.
of
pa
rt
ic
ip
an
ts
—
20
1
A
ct
iv
e
fa
ilu
re
s•
L
ap
se
—
m
is
si
ng
do
cu
m
en

ta
tio
n
•
M
is
ta
ke
—
er
ro
r
in
ca
lc
ul
at
io
n
•
V
io
la
tio
n—
im
pr
op
er
us

e
of
ho
sp
ita
lp
ro
to
co
l
Pa
zo
ki
an
et
al
.
20
14
,I
ra
n
[4
7]
Se
m
i-
st
ru
ct

ur
ed
in
di
vi
du
al
in
te
rv
ie
w
s
Se
tti
ng
—
ac
ad
em
ic
ho
sp
ita
l
Pa
rt
ic
ip
an
ts
—

nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
20
A
ct
iv
e
fa
ilu
re
s
•
M
is
ta
ke
—
pr
es
cr

ib
in
g
w
ro
ng
m
ed
ic
at
io
ns
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
Po
o
do
cu

m
en
ta
tio
n
•
Po
or
kn
ow
le
dg
e
L
at
en
tf
ai
lu
re
s
•
L
ac
k
of
at
te
nt
io

n
of
m
an
ag
er
s
to
st
af
fp
hy
si
ca
la
nd
ps
yc
ho
lo
gi
ca
li
ss
ue
s
le
ad
in
g
to
de

cr
ea
se
in
nu
rs
es
’
m
ot
iv
at
io
n
•
R
is
k
m
an
ag
em
en
ts
tr
at
eg
ie
s
in
su
ff
ic

ie
nt
Sh
ah
ro
kh
ie
t
al
.
20
13
,I
ra
n
[4
8]
C
ro
ss
-s
ec
tio
na
ls
ur
ve
y
Se
tti
ng

—
ac
ad
em
ic
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
nu
rs
es
N
o.
of
pa
rt
ic
ip
an
ts
—
15
0

A
ct
iv
e
fa
ilu
re
s
•
M
is
ta
ke
—
in
co
rr
ec
t
tr
an
sc
ri
pt
io
n
E
rr
or
-p
ro
du

ci
ng
co
nd
iti
on
s
•
E
xc
es
si
ve
w
or
kl
oa
d•
In
ad
eq
ua
te
ph
ar
m
ac
ol
og
ic
al

kn
ow
le
dg
e
•
Sh
or
ta
ge
of
tim
e
L
at
en
tf
ai
lu
re
s
•
L
ow
nu
rs
e
to

pa
tie
nt
ra
tio
•
In
ad
eq
ua
te
nu
m
be
r
of
st
af
f
in
ea
ch
w
or
ki
ng
sh
if
t

•
Si
m
ila
r
dr
ug
pa
ck
in
g
Sh
eh
at
a
et
al
.
20
15
,E
gy
pt
[4
9]
R
et
ro
sp

ec
tiv
e
an
al
ys
is
fr
om
in
ci
de
nt
re
po
rt
in
g
sy
st
em
Se
tti
ng
—
go
ve
rn
m
en
t

an
d
pr
iv
at
e
ho
sp
ita
ls
Pa
rt
ic
ip
an
ts
—
no
t
re
le
va
nt
N
o.
of
pa
rt
ic
ip
an

ts
—
12
00
re
po
rt
s
A
ct
iv
e
fa
ilu
re
s
•
L
ap
se
—
la
ck
of
do
cu
m
en
ta
tio

n
E
rr
or
-p
ro
du
ci
ng
co
nd
iti
on
s
•
L
ac
k
of
kn
ow
le
dg
e
an
d
ex
pe
ri
en

Annotated BibliographyDue Thursday, November 10th· .docx

Annotated BibliographyDue Thursday, November 10th· .docx

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