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What do double-check routines actually detect? An observational assessment and qualitative analysis of identified
Yvonne Pfeiffer1, Chantal Zimmermann2, David L B Schwappach3,2
1Swiss Patient Safety Foundation, Asylstr, Zurich, Switzerland pfeiffer@patientensicherheit.ch.
Objectives:
Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.
Design:
In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.
Setting:
Oncological wards and ambulatory infusion centres of three Swiss hospitals.
Participants:
Nurses' double checking was observed.
Outcome Measures:
In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.
Results:
In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.
Conclusions:
In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.
Insights
Double checking chemotherapy orders in oncology detected potential medication errors in 3.2% of cases. This process helps identify and correct errors early, improving patient safety in cancer care.
Area of Science:
- Oncology
- Pharmacy
- Patient Safety
Background:
- Double checking chemotherapy orders is a critical step to prevent medication errors.
- Potential medication errors can occur at various stages of the chemotherapy administration process.
Purpose of the Study:
- To determine the frequency of potential medication errors detected during chemotherapy double checks.
- To understand the nature and causes of inconsistencies identified during the double-checking process.
Main Methods:
- Observational study of nurses' double-checking procedures in Swiss hospitals.
- Qualitative analysis of detected inconsistencies using a developed category system.
Main Results:
- 28 chemotherapy-related inconsistencies were detected in 3.2% of 690 observed double checks.
- Inconsistencies involved non-matching information or nurses' knowledge-based identification.
- 75% of inconsistencies stemmed from inappropriate orders, leading to corrective actions.
Conclusions:
- Double checking reviews medication plausibility and corrects errors made earlier in the ordering process.
- This process offers opportunities to enhance the overall medication management in oncology.
- Improving the medication process through double checks contributes to better patient safety in cancer treatment.
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