Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach

Area of Science:

• Human Factors Engineering
• Patient Safety
• Medication Administration

Background:

• Independent double checks (IDC) are a common safety measure for high-alert medications.
• The effectiveness of IDC in improving patient safety in pediatric intensive care units (PICUs) requires further investigation.

Purpose of the Study:

• To evaluate if independent double checks (IDC) for high-alert medications enhance patient safety compared to a single check process.
• To assess the impact of IDC on medication administration events, patient outcomes, and nursing workflow.

Main Methods:

• A human factors engineering-led initiative was conducted in a 24-bed PICU.
• Reviewed 37,968 high-alert medication administrations over 40 months, comparing IDC with single checks.
• Assessed medication administration events, hospital length of stay, patient mortality, and nursing time and favorability.

Main Results:

• No significant difference in reported medication administration events between IDC and single checks (P = 0.4939).
• IDC did not significantly alter patient mortality (P = 0.8784) or length of stay (P = 0.4763).
• Nursing time per double check averaged 9.7 minutes versus 1.94 minutes for a single check, with increased nurse favorability for single checks.

Conclusions:

• Independent double checks for high-risk medications in a PICU setting showed no impact on reported medication events compared to single checking.
• The findings suggest that the current IDC protocol may not be an effective patient safety enhancement in this context.
• The study highlights the significant time burden and potential workflow inefficiencies associated with IDC.