Nurses' Adherence to Double-Checking: A Systematic Review of Influencing Factors, Improvement Strategies, and Their...

This systematic review aims to systematically (1) synthesize factors of nurses' adherence to double-checking, (2) identify and describe strategies used to improve adherence, and (3) assess the reported effectiveness of these strategies.

Medication administration errors are a major cause of adverse events. While two-nurse double-checking is widely mandated, nurses' adherence is inconsistent and often not performed independently or is omitted when clinical demands compete. Existing reviews have not fully synthesized adherence determinants and improvement approaches across the work system.

Following PRISMA guidelines, we searched the CINAHL, PubMed, Embase, and Cochrane databases from inception to November 17, 2024. Peer-reviewed studies examining adherence determinants and evaluating adherence-improvement strategies were included. Determinants were mapped to a human factors engineering paradigm, and strategy findings were synthesized narratively.

Factors affecting adherence included interruptions, unavailability of a second nurse, high workload or time pressure, low perceived risk or necessity of double-checking, and crowded medication rooms. Strategies used included written or visual reminders, education with feedback, and barcode-supported auditing systems. Studies also reported that education paired with visual reminders and co-sign tools, ongoing feedback with workflow integration, and protocolized barcode-supported auditing improved adherence; however, evaluations were limited and inconsistent.

Non-adherence largely reflects constraints at all levels of the work system. Therefore, feasible and sustainable independent double-checking requires the redesign of tasks, workflows, physical space and environments, resource allocation, and enabling mechanisms.

Practical support should enable independent cognitive verification, timely access to a second checker, and safe communication during verification. Policies should define independent double-checking, target requirements to higher-risk situations, and pair mandates with staffing, workflow design, and usable technology that make adherence to double-checking feasible and reviewable.