Strategies to mitigate adverse events in medication administration: an integrative review
DOI:
https://doi.org/10.55892/jrg.v9i20.3002Keywords:
Nursing team, Medication errors, Patient safetyAbstract
Introduction: Patient safety is defined as minimizing the risk of unnecessary harm associated with healthcare. One of the greatest challenges in this area is medication administration errors, recognized as the second most common type of clinical error and representing a significant risk to the health and lives of those being cared for. Objective: To analyze, based on the scientific literature, the mitigation strategies used by the nursing team in the occurrence of medication administration errors. Method: An integrative literature review conducted in eight databases and libraries, guided by the following question: "How does the nursing team's performance help mitigate adverse events related to medication use?" Results: 522 studies were identified, and after the selection process, 8 were included in the review. After reading and analysis, the articles were grouped by similarity into four thematic classes: technological strategies and standardization of care processes; educational and safety culture strategies; care transition strategies and high-risk environments; and strategies to support nursing and safety culture. Final considerations: Mitigation strategies depend on a systemic approach, in which the nursing team's performance is central. However, the effectiveness of this performance is directly related to institutional support, which must guarantee standardized protocols, supporting technology, and continuous investment in strengthening a robust safety culture. The standardization of processes and continuing education, combined with human engagement and multiprofessional integration, constitute the most sustainable path to minimize risks and strengthen the quality of care.
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References
COELHO, F. et al. Predisposing Factors to Medication Errors by Nurses and Prevention Strategies: A Scoping Review of Recent Literature. Nursing Reports, [S. l.], v. 14, n. 3, p. 1553-1569, 2024. Disponível em: https://pubmed.ncbi.nlm.nih.gov/39051353/. Acesso em: 17 nov. 2025.
COIMBRA, Jorséli Angela Henriques; CASSIANI, Silvia Helena de Bortoli. Responsabilidade da enfermagem na administração de medicamentos: algumas reflexões para uma prática segura com qualidade de assistência. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 9, n. 2, p. 56–60, 2001. Disponível em: https://www.scielo.br/j/rlae/a/8zQnSMpFDHvp7YcDXQZFJZw/?format=html&lang=pt. Acesso em: 21 nov. 2025.
ELDIN, Y. K. Z.; ABDELLAA, N. H. A relação entre o clima de segurança percebido, o ambiente de trabalho dos enfermeiros e as barreiras para o relato de erros de administração de medicamentos. Life Science Journal, [S. l.], v. 10, n. 1, 2013. Disponível em: http://www.lifesciencesite.com. Acesso em: 17 nov. 2025.
HANNAWA, A. F. et al. The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. Patient Education and Counseling, [S. l.], v. 105, n. 6, p. 1561-1570, 2022. Disponível em: https://pubmed.ncbi.nlm.nih.gov/34690012/. Acesso em: 17 nov. 2025.
KALENDER, Z. T.; TOZAN, H.; VAYVAY, O. Prioritization of Medical Errors in Patient Safety Management: Framework Using Interval-Valued Intuitionistic Fuzzy Sets. Healthcare, [S. l.], v. 8, n. 3, p. 265, 2020. Disponível em: https://pubmed.ncbi.nlm.nih.gov/32806625/. Acesso em: 17 nov. 2025.
LATIMER, S. et al. Medication reconciliation at hospital discharge: A qualitative exploration of acute care nurses' perceptions of their roles and responsibilities. Journal of Clinical Nursing, Hoboken, v. 32, n. 7-8, p. 1276-1285, abr. 2023. Disponível em: https://doi.org/10.1111/jocn.16275. Acesso em: 2 nov. 2025.
MENDES, Karina Dal Sasso; SILVEIRA, Renata Cristina de Campos Pereira; GALVÃO, Cristina Maria. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enfermagem, Florianópolis, v. 17, n. 4, p. 758–764, out./dez. 2008. Disponível em: https://www.scielo.br/j/tce/a/XzFkq6tjWs4wHNqNjKJLkXQ/?format=html&lang=pt .17 nov. 2025.
NAMNABATI, M.; TALEGHANI, F.; VARZESHNEJAD, M. Nursing Satisfaction with Medication Care by Using Neonatal Electronic Medication Management Systems. Iranian Journal of Neonatology, Isfahan, v. 8, n. 4, p. 43-56, 2017. Disponível em: http://ijn.mums.ac.ir. Acesso em: 17 nov. 2025.
OUZZANI, Mourad; HAMMADY, Hossam; FEDOROWICZ, Zbys; ELMAGARMID, Ahmed. Rayyan: a web and mobile app for systematic reviews. Systematic Reviews, London, v. 5, n. 210, p. 1–10, 2016. Disponível em: file:///C:/Users/caios/Downloads/s13643-016-0384-4.pdf. Acesso em 17 nov. 2025.
Page M. J., et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. The BMJ, [S. l.], v. 372, n. 71, p. 1-9, 2021. Disponível em: https://www.bmj.com/content/bmj/372/bmj.n71.full.pdf. Acesso em 17 nov. 2025.
INSTITUTE OF MEDICINE (US) COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA. To Err is Human: Building a Safer Health System. Washington, 2000. Disponível em: https://pubmed.ncbi.nlm.nih.gov/25077248/. Acesso em 17 nov. 2025.
SANTOS, Cristina Mamédio da Costa; PIMENTA, Cibele Andrucioli de Mattos; NOBRE, Moacyr Roberto Cuce. A estratégia pico para a construção da pergunta de pesquisa e busca de evidências. Revista Latino-Americana de Enfermagem, São Paulo, v.12, n. 3, p. 1-4, mai,/jun. 2007.Disponível em: https://www.scielo.br/j/rlae/a/CfKNnz8mvSqVjZ37Z77pFsy/?format=pdf&lang=pt. Acesso em: 2 nov. 2025
SANTOS, P. R. A. dos; ROCHA, F. L. R.; SAMPAIO, C. S. J. C. Ações para segurança na prescrição, uso e administração de medicamentos em unidades de pronto atendimento. Revista Gaúcha de Enfermagem, Porto Alegre, v. 40, n. esp, e20180347, 2019. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1186/987. Acesso em: 2 nov. 2025.
SILVA, R. A. da; CAREGNATO, R. C.; FLORES, C. D. Segurança na administração de medicamentos: utilização do software Bizagi® e a aplicação dos pilares do Triple Aim. Vigilância Sanitária em Debate: Sociedade, Ciência & Tecnologia. Rio de Janeiro, v. 7, n. 1, p. 60-70, fev. 2019. Disponível em: https://doi.org/10.22239/2317-269x.01186. Acesso em: 2 nov. 2025.
SOUZA, F. S. de et al. Enhancing healthcare resilience: systemic medication errors debate in emergency departments with Soft System Methodology. Ciência & Saúde Coletiva, Rio de Janeiro, v. 30, n. 6, p. 1-14, jun. 2025. Disponível em: https://www.scielo.br/j/csc/a/RBkjdGLcVmvnMZp5cF8Zpzk/?lang=en#top. Acesso em: 17 nov. 2025.
SOUZA, Marcela Tavares de; SILVA, Michelly Dias da; CARVALHO, Rachel de. Revisão integrativa: o que é e como fazer. Einstein, São Paulo, v. 8, n. 1, p. 102–106, jan./mar. 2010. Disponível em:< https://www.scielo.br/j/eins/a/ZQTBkVJZqcWrTT34cXLjtBx/?format=pdf&lang=pt>. Acesso em: 17 nov. 2025.
TSEGAYE, D. et al. Medication Administration Errors and Associated Factors Among Nurses. International Journal of General Medicine, [S. l.], v. 13, p. 1621-1632, 2020. Disponível em: file:///C:/Users/caios/Downloads/ijgm-13-1621%20(1).pdf. Acesso em: 17 nov. 2025.
WANGMO, P. et al. Improving drug charting practices and documentation among nurses in emergency department at a regional hospital, Bhutan: a quality improvement initiative. BMJ Open Quality, [S. l.], v. 13, n. 1, e003188, 2024. Disponível em: https://onlinelibrary.wiley.com/doi/10.1111/jocn.16275. Acesso em: 17 nov. 2025.
Wiegmann D. A. et al. Understanding the "Swiss Cheese Model" and Its Application to Patient Safety. J Patient Saf, v. 18, n. 2, p. 119-123, mar. 2022. Disponivel em: https://pmc.ncbi.nlm.nih.gov/articles/PMC8514562/pdf/nihms-1651282.pdf. Acesso em: 22 nov. 2025.
WHO. Patient safety. World Health Organization, 2024. Disponível em: https://www.who.int/news-room/fact-sheets/detail/patient-safety. Acesso em: 18 nov. 2025.
YOUSEF, N.; YOUSEF, F. Using total quality management approach to improve patient safety by preventing medication error incidences. BMC Health Services Research, [S. l.], v. 17, n. 621, 2017. Disponivel em: file:///C:/Users/caios/Downloads/s12913-017-2531-6%20(3).pdf. Acesso em 17 nov. 2025.
