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Related Experiment Video

Updated: Jul 2, 2025

Improving IV Insulin Administration in a Community Hospital
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Published on: June 11, 2012

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Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration:

Sharon A van Stralen1, Linda van Eikenhorst1, Astrid S Vonk1

  • 1Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands.

Heliyon
|February 21, 2024
PubMed
Summary

Nurses often skip medication double-checks due to time pressure, relying on risk assessments instead. This study explored variations in high-risk medication administration and decision-making processes.

Keywords:
Double checkPatient safetyWork-As-DoneWork-As-Imagined

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Area of Science:

  • Healthcare quality and safety
  • Medication administration protocols
  • Nursing practice research

Background:

  • Compliance with double-check protocols for high-risk medication administration is often low.
  • Despite low compliance, most high-risk medication administrations occur without incident.
  • This study examined variations in the preparation and administration of high-risk medications in daily practice.

Purpose of the Study:

  • To investigate the process of preparing and administering high-risk medications.
  • To identify variations occurring in daily nursing practice.
  • To understand the considerations influencing deviations from established guidelines.

Main Methods:

  • Functional Resonance Analysis Method (FRAM) applied to model guidelines and daily practice.
  • Ten Dutch hospital wards participated.
  • Semi-structured interviews with 77 nurses to explore preparation and administration practices and decision-making.

Main Results:

  • Six deviations identified between guideline and practice models.
  • Four variations in double-check procedures were observed, often influenced by time pressure.
  • Nurses performed risk assessments, considering patient stability and calculation complexity, to decide on executing double-checks.

Conclusions:

  • Time pressure is a primary barrier to performing medication double-checks.
  • Nurses utilize risk assessments and trust in expertise to justify deviations from double-check protocols.
  • Future research should adapt double-check procedures for practical feasibility while ensuring patient safety.