A Comparative Scoping Review of Medication Error Reporting in Malaysia and International Healthcare Systems Using the Swiss Cheese Model
DOI:
https://doi.org/10.31674/mjmr.2026.v010i02.08Abstract
Background: Medication errors (MEs) are a persistent global threat to patient safety and underreporting remains widespread. The Swiss Cheese Model (SCM) offers a framework to analyse system-level barriers and defences. Objectives: This scoping review aimed to compare Malaysian and international medication error reporting (MER) practices, map them to the SCM’s six defence layers and identify strategies to strengthen Malaysia’s reporting culture. Methods: Articles included were comprehensively checked for reliability in line with JBI (critical appraisal checklist) and PRISMA-ScR guidelines, hence a systematic search of Scopus, PubMed, Web of Science, ScienceDirect and Google Scholar from (2015–2025) yielded 489 records; 33 studies met inclusion criteria. Results: International studies demonstrated stronger SCM alignment through interdisciplinary reporting, anonymous electronic platforms (e.g., MEDMARX, CIRS), “structured feedback and non-punitive cultures”. By contrast, Malaysian systems showed pharmacist-driven reporting, limited training, punitive cultures and weak feedback mechanisms. Conclusion: Strengthening Malaysia’s MER requires anonymous platforms, just culture policies, structured training and feedback integration, embedding SCM principles to advance safer and more accountable healthcare systems.
Keywords:
Global Healthcare, Malaysia, Medication Error Reporting, Nurses, Swiss Cheese ModelDownloads
References
Ab Rahman, N., Low, E. V., Kamaruddin, F., Che Ayub, A., Chong, S. C., Tumiran, N., & Idris, N. (2025). A retrospective study on prevalence, characteristics, and outcomes of transcribing error: analysis of data from the National Medication Error Reporting System in Malaysia. Journal of Pharmaceutical Policy and Practice, 18(1), 2528244. https://doi.org/10.1080/20523211.2025
Abdullah, D. C., Ibrahim, N. S., & Ibrahim, M. I. M. (2004). Medication errors among geriatrics at the outpatient pharmacy in a teaching hospital in Kelantan. The Malaysian Journal of Medical Sciences: MJMS, 11(2), 52.
Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1), 1156. https://doi.org/10.1186/s12913-021-07187-5
Ali, S., Aboheimed, N. I., Al-Zaagi, I. A., & Al-Dossari, D. S. (2017). Analysis of medication errors at a large tertiary care hospital in Saudi Arabia: a retrospective analysis. International Journal of Clinical Pharmacy, 39(5), 1004-1007. https://doi.org/10.1007/s11096-017-0514-7
Alotaibi, J. S. (2024). Causes of medication administration errors and barriers to reporting as perceived by nurses in Saudi Arabia: A qualitative study. Belitung Nursing Journal, 10(2), 215–221. https://doi.org/10.33546/BNJ.3249
Alotaibi, M. S., Alotaibi, M. S., Aldossri, S. M. M., Alsahli, M. A. A., Alzahrani, N. H., Alsubai, N. A., Hadi, N. M., Al_Qariqri, F. A., Alwddani, I. Y., Aldossari, O. S., Alshehri, K. M., Alsahli, A. A. A., Alotaibi, N. S., Machajy, M. Y., & Alanezi, A. A. (2022). The effect of effective nurse-patient communication on healthcare quality. Journal of Namibian Studies: History Politics Culture, 32, 1233–1246. https://namibian-studies.com/index.php/JNS/article/view/6540
Alqubaisi, M., Tonna, A., Strath, A., & Stewart, D. (2016). Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework. European Journal of Clinical Pharmacology, 72(7), 887-895. https://doi.org/10.1007/s00228-016-2054-9
Alrasheadi, B. A. A. (2019). The relationship between perceived safety culture, nursing leadership and medication errors reporting (by nurses) in a Saudi Arabian context: A sequential explanatory mixed method design (Doctoral dissertation, University of Central Lancashire). https://knowledge.lancashire.ac.uk/id/eprint/29162/
Alrasheeday, A. M., Alkubati, S. A., Alrubaiee, G. G., Alqalah, T. A., Alshammari, B., Abdullah, S. O., & Loutfy, A. (2024). Estimating proportion and barriers of medication error reporting among nurses in Hail City, Saudi Arabia: Implications for improving patient safety. Journal of Multidisciplinary Healthcare, 2601-2612. https://doi.org/10.2147/JMDH.S466339
Alshammari, F. M., Alanazi, E. J., Alanazi, A. M., Alturifi, A. K., & Alshammari, T. M. (2021). Medication error concept and reporting practices in Saudi Arabia: a multiregional study among healthcare professionals. Risk Management and Healthcare Policy, 2395-2406. https://doi.org/10.2147/RMHP.S281154
Anderson, J. G., & Abrahamson, K. (2017). Your health care may kill you: Medical errors. Studies in Health Technology and Informatics, 234, 13–17. https://doi.org/10.3233/978-1-61499-742-9-13
Braiki, R., Douville, F., & Gagnon, M. P. (2024). Factors influencing novice and beginner nurses’ intention to report medication errors and near misses. Canadian Journal of Nursing Research, 56(4), 448-456. https://doi.org/10.1177/08445621241263438
Burns, N., Alkaisy, Z., & Sharp, E. (2018). Doctors attitudes towards medication errors at 2002 & 2015. International Journal of Health Care Quality Assurance, 31(6), 451–463. https://doi.org/10.1108/IJHCQA-04-2016-0038
Chew, C.-C., HS, A.-S., Abd Manak, N. R. H., Azlan, N., Raida Haron, A. B., Husin, S., Abdullah, S., Ee, C. H.-X., Nachiappan, J., Mohd Noor, S., & Hss, A.-S. (2022a). Medication administration errors reporting by Neonatal Intensive Care Nurses in Malaysia: A nationwide study. Malaysian Journal of Paediatrics and Child Health, 28(2), 5–12. https://doi.org/10.51407/mjpch.v28i2.179
Collins, S. J., Newhouse, R., Porter, J., & Talsma, A. (2014). Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. AORN Journal, 100(1), 65-79. https://doi.org/10.1016/j.aorn.2013.07.024
Del Puerto, C. J. C. (2024). Nurses' Medication Administration Error, Reporting Practices and Challenges in Tertiary Hospitals: Descriptive Analysis. Philippine Journal of Nursing, 94(2). https://openurl.ebsco.com/EPDB%3Agcd%3A11%3A11896539/detailv2?sid=ebsco%3Aplink%3Ascholar&id=ebsco%3Agcd%3A181669621&crl=c&link_origin=scholar.google.com
Diller, T., Helmrich, G., Dunning, S., Cox, S., Buchanan, A., & Shappell, S. (2014). The human factors analysis classification system (HFACS) applied to health care. American Journal of Medical Quality, 29(3), 181-190. https://doi.org/10.1177/1062860613491623
Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931-938. https://doi.org/10.1111/jocn.14716
Durstenfeld, M. S., Statman, S., Dikman, A., Fallahi, A., Fang, C., Volpicelli, F. M., & Hochman, K. A. (2019). The Swiss cheese conference: integrating and aligning quality improvement education with hospital patient safety initiatives. American Journal of Medical Quality, 34(6), 590-595. https://doi.org/10.1177/1062860618817638
Elden, N. M. K., & Ismail, A. (2015). The Importance of Medication Errors Reporting in Improving the Quality of Clinical Care Services. Global Journal of Health Science, 8(8), 243. https://doi.org/10.5539/gjhs.v8n8p243
George, D., Amar-Singh, H. S. S., & Hassali, A. (2018). Medication error reporting: underreporting and acceptability of smartphone application for reporting among health care professionals in Perak, Malaysia. Cureus, 10(6). https://doi.org/10.7759/cureus.2746
Gleeson, L., Dalton, K., O'Mahony, D., & Byrne, S. (2020). Interventions to improve reporting of medication errors in hospitals: A systematic review and narrative synthesis. Research in Social and Administrative Pharmacy, 16(8), 1017-1025. https://doi.org/10.1016/j.sapharm.2019.12.005
Guo, H., Guo, Q., Wang, X., Liu, Y., & Wang, Z. (2025). Exploring multidimensional determinants of medication error reporting in China: a qualitative study using the theoretical domains framework. Frontiers in Pharmacology, 16, 1590794. https://doi.org/10.3389/fphar.2025.1590794
Henry Basil, J., Premakumar, C. M., Mhd Ali, A., Mohd Tahir, N. A., Seman, Z., Voo, J. Y. H., ... & Mohamed Shah, N. (2025). Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: a multicentre, nationwide direct observational study. Journal of Advanced Nursing, 81(2), 820-833. https://doi.org/10.1111/jan.16247
Ishak, M. S., & Ibrahim, M. I. (2024). Critical Care Nurses’ Perception of Medication Administration Errors in Kelantan, Malaysia: A Cross‐Sectional Study. Journal of Nursing Management, 2024(1), 3055826. https://doi.org/10.1155/2024/3055826
Jang, S. J., Lee, H., & Son, Y. J. (2021). Perceptions of patient safety culture and medication error reporting among early-and mid-career female nurses in South Korea. International Journal of Environmental Research and Public Health, 18(9), 4853. https://doi.org/10.3390/ijerph18094853
JBI. (2021). JBI Critical Appraisal Tool. Faculty of Health and Medical Science the University of Adelaide. https://jbi.global/critical-appraisal-tools
Keefer, P., Kidwell, K., Lengyel, C., Warrier, K., & Wagner, D. (2017). Variability in threshold for medication error reporting between physicians, nurses, pharmacists, and families. Current Drug Safety, 12(3), 187-192. https://doi.org/10.2174/1574886312666170724163439
Kumar, M., Sahni, N., Shafiq, N., & Yaddanapudi, L. N. (2022). Medication prescription errors in the intensive care unit: prospective observational study. Indian Journal of Critical Care Medicine: Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 26(5), 555-557. https://doi.org/10.5005/jp-journals-10071-24148
Lee, E. (2017). Reporting of medication administration errors by nurses in South Korean hospitals. International Journal for Quality in Health Care, 29(5), 728-734. https://doi.org/10.1093/intqhc/mzx096
Li, W. C., & Harris, D. (2006). Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents. Aviation, Space, and Environmental Medicine, 77(10), 1056-1061. https://asma.kglmeridian.com/meridian/asma/published/rest/pdf-watermark/v1/journals/asem/77/10/article-p1056.pdf/watermark-pdf/
Mahfodz, M. M., Siddiqui, S., & Zainal, H. (2024). Knowledge, attitude and practices about pharmacovigilance activities among hospital nurses: a multicentre cross-sectional survey. Journal of Research in Nursing, 29(3), 259–274. https://doi.org/10.1177/17449871241232340
Mahmoud, H. A., Thavorn, K., Mulpuru, S., McIsaac, D., Abdelrazek, M. A., Mahmoud, A. A., & Forster, A. J. (2023). Barriers and facilitators to improving patient safety learning systems: A systematic review of qualitative studies and meta-synthesis. BMJ Open Quality, 12(2). https://doi.org/10.1136/bmjoq-2022-002134
Massah, L., Mohammadi, R., & Namnabati, M. (2021). Improvement of medication error reporting: An applied motivation program in pediatric units. Journal of Education and Health Promotion, 10(1), 189. https://doi.org/10.4103/jehp.jehp_1025_20
Ministry of Health Malaysia. (2014). Health facts 2014. Planning Division, Health Informatics Centre. https://www.moh.gov.my/images/04-penerbitan/health-facts/HEALTH%20FACTS%202014.pdf
Ministry of Health of Malaysia. (2011). MOH Annual Report 2011. https://www.moh.gov.my/en/publications-and-reports/infographics-reports-statistics/annual-report/list-of-annual-report/moh-annual-report-2011
Mutair, A. Al, Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. Al, Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046
Neuhaus, C., Huck, M., Hofmann, G., St. Pierre, M., Weigand, M. A., & Lichtenstern, C. (2018). Applying the human factors analysis and classification system to critical incident reports in anaesthesiology. Acta Anaesthesiologica Scandinavica, 62(10), 1403-1411. https://doi.org/10.1111/aas.13213
Patterson, J. M., & Shappell, S. A. (2010). Operator error and system deficiencies: Analysis of 508 mining incidents and accidents from Queensland, Australia using HFACS. Accident Analysis and Prevention, 42(4), 1379–1385. https://doi.org/10.1016/j.aap.2010.02.018
Pongprom, S., Tanthanapanyakorn, P., Khantikulanon, N., Mungkhunthod, S., Praserttai, C., Fangchaiyaphum, R., ... & Harnprasop, Y. (2025). Effectiveness of the ME Online Program to Reduce Medication errors among primary health care units in the city areas of the Thai-Cambodian Border Provinces, Thailand. Journal of Health Science and Medical Research, 43(4), 20251154. https://doi.org/10.31584/jhsmr.20251154
Prihartono, I. P., & Wibowo, A. (2020). Assessment of medication administration error reporting among hospital nurses in Indonesia. Journal of Patient Safety & Quality Improvement, 8(1), 13-23. https://doi.org/10.22038/psj.2020.43466.1244
Reason, J. (2000). Human error: models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Reinach, S., & Viale, A. (2006). Application of a human error framework to conduct train accident/incident investigations. Accident Analysis & Prevention, 38(2), 396-406. https://doi.org/10.1016/j.aap.2005.10.013
Relihan, E., O'Brien, V., O'Hara, S., & Silke, B. (2010). The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Quality and Safety in Health Care, 19(5), e52-e52. https://doi.org/10.1136/qshc.2009.036871
Saada, M. (2023). Healthcare professional’s knowledge and awareness of the medication error reporting systems in the Kuwaiti hospitals. Current Issues in Pharmacy and Medical Sciences, 36(2), 87–93. https://doi.org/10.2478/cipms-2023-0015
Sabila, F. C., Oktarlina, R. Z., & Utami, N. (2018). Peresepan elektronik (E-Prescribing) dalam menurunkan kesalahan penulisan resep [Electronic prescribing (E-Prescribing) in reducing prescription writing errors]. Majority, 7(3), 271-275. http://juke.kedokteran.unila.ac.id/index.php/majority/article/view/2090
Samsiah, A., Othman, N., Jamshed, S., & Hassali, M. A. (2016). Perceptions and attitudes towards medication error reporting in primary care clinics: a qualitative study in Malaysia. PLoS One, 11(12), e0166114. https://doi.org/10.1371/journal.pone.0166114
Samsiah, A., Othman, N., Jamshed, S., & Hassali, M. A. (2020). Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics. International Journal of Clinical Pharmacy, 42(4), 1118-1127. https://doi.org/10.1007/s11096-020-01041-0
Spiess, B. D., Rotruck, J., McCarthy, H., Suarez-Wincosci, O., Kasirajan, V., Wahr, J., & Shappell, S. (2015). Human factors analysis of a near-miss event: oxygen supply failure during cardiopulmonary bypass. Journal of Cardiothoracic and Vascular Anesthesia, 29(1), 204-209. https://doi.org/10.1053/j.jvca.2014.08.011
Stewart, D., Thomas, B., MacLure, K., Wilbur, K., Wilby, K., Pallivalapila, A., ... & Al Hail, M. (2018). Exploring facilitators and barriers to medication error reporting among healthcare professionals in Qatar using the theoretical domains framework: A mixed-methods approach. PloS one, 13(10), e0204987. https://doi.org/10.1371/journal.pone.0204987
Thomas, B., Pallivalapila, A., El Kassem, W., Al Hail, M., Paudyal, V., McLay, J., ... & Stewart, D. (2021). Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar. International Journal of Clinical Pharmacy, 43(1), 77-84. https://doi.org/10.1007/s11096-020-01108-y
Thonon, H., Espeel, F., Frederic, F., & Thys, F. (2020). Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. Acta Clinica Belgica: International Journal of Clinical and Laboratory Medicine, 75(3), 193–199. https://doi.org/10.1080/17843286.2019.1592738
Wiegmann, D. A., & Shappell, S. A. (2017). A human error approach to aviation accident analysis: The human factors analysis and classification system. Routledge.
Wiegmann, D. A., Wood, L. J., Cohen, T. N., & Shappell, S. A. (2022). Understanding the “Swiss Cheese Model” and its application to patient safety. Journal of Patient Safety, 18(2), 119-123. https://doi.org/10.1097/PTS.0000000000000810
World Health Organization. (2017). Medication Without Harm WHO Global Patient Safety Challenge. https://www.who.int/initiatives/medication-without-harm
Yang, L., Peng, X., Song, W., Su, H., Wang, C., Yang, S., & Wu, D. (2025). The barriers to medication error reporting by nurses and factors associated with it: a cross-sectional study in a tertiary hospital of south-west China. BMJ open, 15(4), e091058. https://doi.org/10.1136/bmjopen-2024-091058
Yatim, M. F. M., & Othman, N. H. (2022). A retrospective analysis of medication errors at a tertiary hospital in a northern state of Malaysia. Malaysian Journal of Pharmaceutical Sciences, 20(2), 79-92. https://doi.org/10.21315/mjps2022.20.2.7
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