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Misreading Injectable Medications—Causes and Solutions: An Integrative Literature Review
Journal article

Misreading Injectable Medications—Causes and Solutions: An Integrative Literature Review

Heather Borradale, Patrea Andersen, Marianne Wallis and Florin Oprescu
Joint Commission journal on quality and patient safety, Vol.46(5), pp.291-298
05/2020
DOI: https://doi.org/10.1016/j.jcjq.2020.01.007
PMID: 32151563

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2 Times Cited - Web of Science

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Source: InCites

Abstract

This integrative review examines research identifying the misreading of injectable medications as a cause of medication error in hospitals, factors affecting injectable medication visibility leading to medication errors, and interventions to increase the readability of injectable medications. Signal detection theory (SDT) is applied to explain why visual enhancement of injectable medications may improve accuracy of administration. Academic health databases were searched for articles published between 2000 and 2019. An integrative review methodology permitted exploration and critique of both theoretical and empirical literature. Fifteen studies reported that misreading injectable medications contributed to medication errors. Five studies investigated interventions to improve visualization of injectable medications. SDT suggested three factors may contribute to misreading injectable medications: (1) environmental light levels, (2) medication labels, and (3) clinician factors. Although the literature on this topic was limited and not definitive, results of this review indicated possible ways to improve practice and targets for future research to reduce medication errors due to misreading injectable medication labels.

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