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Medication error, Nursing, Stem cell transplantation



  1. Pereira Lermontov, Simone MSc
  2. Carreiro Brasil, Simone MSc
  3. Rezende de Carvalho, Magali MSc


Background: There have been numerous efforts by health institutions and professionals to prevent and reduce medication errors.


Objectives: The aim of this study was to identify in the literature the incidence, related factors, consequences, and prevention mechanisms of medication errors in the context of hematopoietic stem cell transplantation.


Methods: This is a systematic review carried out in the databases LILACS, PubMed, PMC, EMBASE, and CINAHL databases, from January 11 to 13, 2017.


Results: Eleven studies were included in this review and presented in 4 categories of analysis. (1) occurrence-most of the medication errors were related to administration and prescription; (2) related factors-multicausal, highlighting issues including polypharmacy, lack of double checking, and similarity between the medications' names; (3) consequences-the main ones were associated with adverse reactions, with prolonged hospitalization time as outcome; (4) preventive measures-related to safe practices in pharmacotherapy, such as double check and application of the 10 rights of medication administration.


Conclusion: Medication administration is an activity of great responsibility for nursing; however, in order to achieve a decrease in medication errors, prevention strategies are necessary for the whole health team.


Implications for Practice: Practice improvements are needed including establishing institutional drug administration protocols and keeping them updated, using a computerized prescription system, and promoting patient safety with staff.