Hospital Practices and Research

Medication Errors in Intensive Care Units: A Narrative Review of Prevalence, Contributing Factors, and Consequences, with Evidence-Based Strategies for Safer Practice in India and Other Developing Healthcare Systems

Articles in Press

Document Type : Review Article

Author

Monika Maan

Institute of Liver and Biliary Sciences, New Delhi, India

10.30491/hpr.2026.533108.1498
Abstract
Background: Medication errors (MEs) are among the most common preventable causes of patient harm in healthcare. Their frequency and severity are amplified in Intensive Care Units (ICUs) where patients are critically ill, receive complex and high-risk therapies, and are especially vulnerable to iatrogenic harm.
Objectives: This narrative review aims to synthesize the prevalence, unique contributing factors, and consequences of medication errors in ICU settings, with particular attention to India and other developing healthcare systems, and to outline evidence-based strategies for their prevention.
Methods: A narrative literature review was conducted using peer-reviewed articles, systematic reviews, and reports from recognized health authorities (including the World Health Organization) published mainly between 2008 and 2025. Sources addressing medication error prevalence, causes, and consequences in ICU and critical-care settings were prioritized, with supplementary sources on the broader Indian healthcare and economic context.
Results: Reported ICU medication error prevalence ranges widely, from approximately 1.32% to 31.7% of admissions in global reviews,1 and from 8.1 to 2,344 per 1,000 patient-days,2 reflecting differences in error definitions, detection methods, and reporting cultures across studies. Prescribing and transcription errors dominate in Indian ICUs,3 while administration errors involving intravenous and high-alert medications carry the greatest risk of harm. Errors arise from a complex interaction of workload and staffing pressures, incomplete standardization, communication breakdowns, technological limitations, knowledge gaps, and a persistent culture of blame that discourages reporting. Consequences extend beyond the patient to nurses' psychological well-being and to substantial healthcare-system costs, including prolonged ICU stay and increased treatment expenditure.
Conclusion: Medication errors remain a widespread, costly, and largely preventable threat to ICU patient safety, disproportionately underreported in India and other developing settings. A multi-pronged strategy combining standardized protocols, targeted technology, continuous education, non-punitive reporting systems, workforce well-being, and patient and family engagement is required to reduce this burden meaningfully.

Keywords

Medication Error
Intensive Care Units
Nursing Practice
Patient Safety
India
Error Prevention
Evidence-Based Practice
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