Associations between double-checking and medication administration errors: a direct observational study of paediatric...

Area of Science:

• Healthcare Quality and Safety
• Clinical Pharmacy Practice
• Pediatric Nursing

Background:

• Double-checking medications is a long-standing practice in pediatric hospitals globally.
• Despite its prevalence, empirical evidence supporting its efficacy in reducing medication administration errors (MAEs) or harm is limited.

Purpose of the Study:

• To evaluate the association between double-checking practices and the incidence and potential severity of MAEs.
• To assess the duration of double-checking procedures.
• To identify factors influencing adherence to double-checking protocols.

Main Methods:

• A direct observational study was conducted with 298 nurses across nine pediatric hospital wards.
• 5140 medication doses administered to 1523 patients were observed in real-time.
• MAEs and their potential severity were identified by comparing observational data with medical records; multivariable regression analyzed associations.

Main Results:

• Mandated double-checking showed no significant association with reduced MAEs (OR 0.89) or severity (OR 0.86).
• When double-checking was not mandated but voluntarily performed, it was associated with fewer MAEs (OR 0.71) and lower potential severity (OR 0.75).
• Each double-check averaged 6.4 minutes, equating to 107 hours per 1000 administrations.

Conclusions:

• High compliance with mandated double-checking was observed, but independent checks were rare.
• Primed double-checking, though common, did not demonstrate a safety benefit over single-checking.
• The study questions the effectiveness and resource implications of current double-checking policies in pediatric settings.