Patient safety is a critical component of the healthcare system [1], but may be hindered by several factors, including medication errors (MEs), which are among the most common mistakes that threaten patient safety [2]. Although MEs occur with substantial frequency in hospital environments, they are significantly more common in units with more severely ill patients, such as the emergency department (ED), with rates ranging from 4% to 68% [3-6]. The unpredictability and complex nature of EDs, the critical situation of most patients, and the heavy workload due to inadequate patient-nurse ratios make the ED a high-risk area for MEs [5,6].

Previous studies have suggested that most MEs made in EDs are by nurses, with higher frequencies during administration of drugs [7-9]. Nurses spend more time with patients than most other healthcare workers and play significant roles in the process of medication management and improving patient safety [10-13]. Therefore, identifying the pattern, prevalence, and factors associated with the occurrence of MEs in the EDs can help nurse managers to develop innovative, data-driven strategies to reduce the incidence of MEs and their negative consequences [14-17]. Despite the importance of MEs in EDs and the critical role of nurses in this regard [18], there is a lack of comprehensive data concerning the prevalence and associated factors of MEs among emergency ward nurses in Iran. Therefore, this study aimed to review the literature on this issue.

As one of the most significant problem in hospitals, MEs have a considerable negative impact on most countries’ healthcare sectors [20-22]. MEs are responsible for the vast majority of iatrogenic injuries [23], prompting healthcare officials around the world to search for effective ways to minimize their occurrence [8,24,25]. Based on the results of the present study, the rate of drug administration errors was high (41.7%). Similarly, a previous study reported that the overall rate of MEs in Iran ranged from 14.3% to 70.0% [26]. Errors such as incorrect timing, omissions, and wrong dosages are linked to inadequate staffing, which imposes a heavy work burden on nurses [2,7,11,17,18,27]. Work overload is known to lead to fatigue [5,28], resulting in a loss of focus that consequently increases the likelihood of errors and adverse events [26,29]. We found that professional experience and education contributed significantly to reducing MEs. Nurses with higher work experience or adequate in-service training were less likely to commit MEs than less experienced nurses [30]. A study by Tang et al. [31] in Taiwan showed that nurses’ inadequate training in the wards was associated with an increased risk of MEs. Another study conducted in Canada showed that insufficient training of the staff contributed to the incidence of MEs, although to a minor extent [32]. Indeed, training has direct advantages, such as augmenting nurses’ level of knowledge and skills and improving the quality of nursing care through the application of the learned knowledge [33]. Thus, frequent in-service training for nurses is beneficial because it increases nurses’ knowledge. Other forms of MEs, such as dispensing errors, which involve dispensing medications that vary from the written orders of prescribers [34], were less widely reported in the current study, primarily because in Iran, dispensing medications is the responsibility of the pharmacist. However, the rates of dispensing and prescribing errors among other health professionals in Iran have been documented elsewhere [26].

We found that the most frequent type of ME was improper administration of medications, including omissions. According to a study by Zeraatchi et al. [11], one of the main reasons for this type of error is the use of the traditional paper-based prescribing systems rather than computerized prescription systems. The former system makes it easy for nurses to misinterpret prescriptions and administer them incorrectly. To minimize this problem, many countries have adopted computerized medical record-keeping, drug compliance systems, bar code systems, drug dispensing systems, and smart pumps to enhance the safety of pharmaceutical processes [35]. Studies have also reported that the presence of clinical pharmacists in hospital wards is one of the best-proven solutions for reducing MEs [17,36]. Zarif-Yeganeh et al. [37] reported that clinical pharmacists in EDs provided accurate drug information and monitored drug distribution, leading to a reduced incidence of MEs. The multidisciplinary team approach proposed by the Agency for Healthcare Research and Quality could serve as a dependable and applicable framework. This approach involves engaging a multidisciplinary team including advanced practice providers, physicians, pharmacists, and nurses to improve medication administration practices and patient safety [38]. However, nurses must ensure that they adhere to the 5 basic “rights” at all times when administering medications: the right patient, the right drug, the right route, the right time, and the right medication. These are effective ways to minimize MEs [39].

Based on the results of this study, it is apparent that MEs by emergency nurses are common occurrences in Iran. However, many go unreported, as suggested by other researchers [18]. Previous studies have indicated that the non-reporting of MEs is mainly due to the fear of consequences, managerial issues such as bureaucracies, and the inappropriate response of managers [26,40]. The lack of accurate information on MEs in Iran could be a sign of a weakness in the system for reporting MEs [26]. Therefore, measures such as the implementation of supportive and non-punitive systems, along with regular training, will help medical staff understand that not reporting errors imposes more significant damages than reporting them [41]. Nurses must be well informed about what constitutes an error, how errors occur, which incidents should be reported, and clear-cut reporting channels [42]. With these measures in place, the rate of MEs could be reduced. Furthermore, managers and decision-makers in the field of nursing should provide appropriate conditions to reduce the incidence of MEs in EDs in Iran. For example, regular training should be organized for the nursing staff, while ensuring that the staffing level matches patient numbers. Doing so will reduce staff workload and fatigue, which are contributors to MEs. Regular training is recommended to keep nurses updated about new medications and drug-administration protocols [43]. Furthermore, nurse authorities and hospital managers should endeavor to established computerized prescribing systems in all hospital units [44]. Computerized systems are effective at carrying out orders and detecting errors, and are not susceptible to basic human shortfalls such as fatigue and forgetfulness [45]. Similarly, computerized systems perform adequate checks, and are effective countermeasures against errors resulting from prescribers’ ineligible handwriting and confusions relating to similar drug names and unclear abbreviations [42]. A limitation of this study is that since it focused on a sensitive topic, the findings of some of the included studies might not have been fully accurate, because nurses may fear the negative consequences of reporting MEs, such as punishments, legal problems, and punitive organizational measures [46]. This possibility may have led to the misrepresentation of some aspects of the results presented herein.

Despite the increased attention on patient safety in Iran, MEs made by nurses remain a significant concern in EDs. Based on our findings, nearly half of the nurses who work in EDs in Iran have made MEs of some type during practice. Inappropriate nurse-patient ratios and nurses’ lack of adequate knowledge about medications are some of the critical factors responsible for MEs. Nurse managers and policy-makers must implement effective measures to reduce the incidence of MEs and its potential negative consequences.