ERRORS IN THE SELF-ADMINISTRATION OF GLP-1 RECEPTOR AGONISTS AND DUAL GIP/GLP-1 AGONISTS: A SCOPING REVIEW

Abstract

Objective: To map errors related to the self-administration of glucagon-like peptide-1 (GLP-1) receptor agonists and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists, their consequences, and the educational strategies proposed in the literature, highlighting their implications for nursing health education. Method: A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). A search was performed in MEDLINE/PubMed in September 2026, with no initial publication date restriction. Two independent reviewers screened the studies, and the identified errors were classified into categories through descriptive analysis. Results: Of the 79 records identified, nine studies were included, published between 2016 and 2026: three pharmacovigilance analyses, one poison control center study, two device usability studies, one case series, and two case reports. Dosing errors were the most frequently reported, followed by pen handling errors, incorrect intervals between administrations, and unsupervised dose escalation. The consequences were predominantly gastrointestinal; however, severe cases involving hypoglycemia and multiple organ dysfunction were also reported. The proposed strategies primarily focused on patient education at treatment initiation and during the first use of the injection pen. Conclusion: Self-administration errors were concentrated at treatment initiation and during dose adjustments. Nursing guidance, including teach-back demonstrations and dose verification, may contribute to preventing these errors and promoting medication safety.