Double checking medicines: defence against error or contributory factor?

Area of Science:

• Healthcare quality and safety
• Medication error reduction strategies
• Human factors in patient safety

Background:

• Double checking medicines is a standard safety procedure in healthcare.
• Its effectiveness is widely assumed but not rigorously tested.
• Variability in the process may undermine its intended benefits.

Purpose of the Study:

• To appraise the process of double checking medicines.
• To identify factors contributing to medication errors during checking.
• To evaluate the consistency and outcomes of medicine double checks.

Main Methods:

• Review of 991 drug error reports.
• Analysis of 40 in-depth interviews with healthcare professionals.
• Exploration of contributory factors in medication errors.

Main Results:

• Medication errors occurred even with double checking.
• Healthcare professionals perceive the double checking process as inconsistent.
• Key issues identified include deference to authority, reduced responsibility, automatic processing, and time constraints.

Conclusions:

• Double checking medicines requires a selective, systematic approach with defined principles and behaviors.
• Psychological research and insights from the aviation industry can enhance error reduction strategies.
• Recommendations are provided to improve the safety and effectiveness of medicine checking.