Let me double check. Or, maybe, let me not…

For decades, nurses around the world have double checked the administration of medications in paediatric hospitals as part of standard practice. But research has continued to show high rates of medication errors in such settings and there is little evidence of double-checking’s effectiveness in reducing them. In a new study, PCHSS’s Professor Johanna Westbrook and colleagues point to some of the shortcomings of double-checking as a strategy to combat the problem.

Photo of doctor explaining medication to patient
Photo credit: Bongkarn Thanyakij / Pexels

Published in BMJ Quality & Safety in August 2020, “Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients” details a direct observational study of 298 nurses attending to over 1,500 patients. Observation was carried out by seven individuals with nursing or pharmacy qualifications that received extensive training that included workshops, simulated cases and infield practice.

Hospital policy stipulates double-checking for the administration of most medications, with only a select group – for example, oral antibiotics and vitamins, topical creams and ointments, laxatives, nasal drops, etc. – not requiring independent double-checking. As such, across a total of 5,140 medication dose administrations, the observers found the majority (3,563) mandated double-checking.

Of these, about 1% received independent double-checks, approximately 6.5% received no double-check or incomplete double-checks, and 92.5% received “primed” double-checks (meaning that another nurse shared information that may have influenced the checking nurse). Assessing all these cases of mandated double-checking, the researchers found no significant association between medication administration error and double-checking. From these results, the authors state that “nurses were highly compliant with mandatory double-checking but failed to ‘independently’ check, despite a clear hospital policy”, meaning that they largely relied on colleagues to prompt them.

One interesting finding of the study, however, concerned situations in which double-checking was not mandated but still performed – involving medications “viewed as presenting lower safety risks to patients in relation to both the likelihood and consequences of any administration errors.” In those cases of double-checking done at the nurses’ discretion, medication errors were less likely. On this subject, the researchers write:

When double-checking was optional (n=1577), and applied (n=416), we found there was a significantly lower odds of the occurrence of a [medication administration error]. For double-checked administrations the error rate was 29/100 and for those not double-checked 37/100 administrations. Dose errors were the most frequent category of [medication administration error] and a lower rate of dose errors in the optional double-check group appeared to drive the overall difference between the double-checked and single-checked groups….

In this connection, Westbrook and colleagues point to the potential implications of their work for hospital policy. Citing other research with comparable outcomes, they note that “even when not compelled by policy, nurses will use their clinical judgement as to when a double-check may be warranted, and in such situations the process may be more likely to confer a benefit.” Given the lack of a strong association between mandated double-checking and medication administration errors, they state that it may be time to reconsider this long-standing practice.

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