- Medication errors are particularly common in the perioperative setting, where patients undergo multiple handoffs and transitions of care while sedated or anesthetized.
- Many studies of the nature and causes of medication errors in the perioperative setting have focused on errors involving anesthetic medications. However, relatively few have focused on errors made by nurses, including perioperative nurses and nurse anesthetists, who are important members of the perioperative team and care for patients throughout their perioperative stay.
- In this scoping review, the authors sought to map the current literature on the incidence and characteristics of nurse-related medication errors in perioperative healthcare settings.
- 967 articles were identified via a database search, of which 7 full-text articles were included in this review.
- These studies demonstrated a wide variation in the incidence of nurse-related medication errors in perioperative settings, ranging from 6.4% to 33.7%.
- Commonly reported administration errors included incorrect programming of infusion pumps, misadministration by IV or subcutaneous routes (particularly in high-risk populations such as pediatric patients), errors specifically related to verbal orders for opioids and antibiotics, and missed or delayed doses.
- Six categories of factors contributing to nurse-related medication errors were identified: people, communication, environment, system/processors, management/organization, and patient factors.
- Communication breakdowns, particularly during handoffs and following verbal orders (both of which are common in the perioperative setting), play a key role in medication errors.
- The authors concluded that many of these contributing factors may be, in part at least, attributable to the fast-paced, high-pressure nature of the perioperative setting coupled with the need for seamless collaboration between different healthcare teams.
- Rapid task-switching, high cognitive demand, and few opportunities for breaks often lead to the development of habitual behaviors or shortcuts and may further increase the risk for medication errors in the perioperative setting.
- Further research is warranted on strategies to mitigate these factors and reduce the risk of nurse-associated medication errors in the perioperative setting.
Summary of "Medication Errors in Perioperative Nursing: A Scoping Review"
Summary published October 12, 2026
