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This column draws on US and Canadian experience and includes, with permission, material
from the ISMP Medication Safety Alert!, a biweekly bulletin published by the Institute for
Safe Medication Practices (ISMP), Huntingdon Valley, Pennsylvania.
DOUBLE-CHECKING: DOES IT WORK?
D
ouble-checking of medication administration by
nurses in hospitals has been a topic of interest as
well as controversy. Proponents have good reasons to
believe that double-checking should and will catch
errors, while critics have argued that it is not an effective
way of preventing errors, nor an efficient way of using
health care resources. Critics are also concerned that the
double-check process might create a false sense of
security. An Australian study examined the safety of
single-person checking (by a registered nurse) of a
designated group of medications. The number of
medication errors reported with single-person checking
was similar to the number reported in a comparable time
frame in a setting where double-person checking was
the standard practice.
1
The recent Medication Safety
Alert! article reproduced below discusses the virtues of
independent double-checking. It quotes Dr Anthony
Grasha, professor of psychology at the University of
Cincinnati, who stresses the importance of independent
checking and the necessary training for proper checking.
The issue of double-checking also affects hospital
pharmacists. Order entry, calculation of doses to be
prepared and dispensed, and dispensing of medications
are important components of the medication-use
process. Will double checks on these functions, carried
out by pharmacists and pharmacy technicians, help to
catch medication errors before patients can be harmed?
At present, hospitals vary widely in terms of double-
checking practices.
When a pharmacist performs computerized
medication order entry, his or her work is not usually
double-checked by another pharmacist, although some
hospitals have policies whereby medication orders are
subject to random checks. In contrast, orders entered by
technicians are usually checked by pharmacists before
they are activated. With regard to the dispensing
function, medications dispensed in a hospital where unit
dosing is the standard are typically filled by technicians
and checked by another technician or pharmacist. The
same applies to the preparation of doses for restocking
of point-of-care dispensing cabinets. In some pharma-
cies, only medications dispensed for critical care areas
are checked. In a traditional drug distribution system,
medications are filled by technicians and checked by
pharmacists. Doses required stat in both unit-dose and
traditional systems are usually checked by a pharmacist
or another technician before delivery or pick-up by a
nurse. In some hospitals where there is only one
pharmacist on duty during weekends and night shifts,
medications may be dispensed without a second check.
If done properly, double-checking by pharmacists
and technicians does play a role in reducing medication
errors. An effective double check must be performed
independently by 2 staff members and should be applied
in cases involving selected high-risk patient groups
(e.g., children) and high-alert medications (e.g.,
chemotherapy). A study on the frequency of 10-fold
dosing errors, published about a year ago by researchers
at the Hospital for Sick Children in Toronto, demonstrated
the impact of errors in complex dosing regimens for
children.
2
Similarly, great efforts should be exerted to
safeguard complex drug regimens for cancer patients.
Hospital pharmacists should make every effort to
perform independent double checks on high-alert
medications such as insulin, opiates, and chemotherapeutic
Medication Safety Alerts
David U
PHARMACY PRACTICE
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168
agents. There have been many reports of mix-ups
involving these types of drugs, as well as reports of
incorrect doses calculated and prepared. Here are a few
tips on preventing the dispensing of the wrong drug and
incorrect dosing with these high-alert drugs:
Use both the generic drug name and the brand
name in order entry.
Where possible, avoid using mnemonics for
high-alert drugs.
If computer mnemonics are used for these drugs,
make sure that they are clearly distinguished and do
not look alike or sound alike.
Perform checks of dosing calculations from
scratch; the person performing the check should
not be aware of how the first calculation was done
or its result.
Be familiar with dosing parameters, e.g., body
surface area calculations for chemotherapy, and
body surface area, weight, and pharmacokinetic
calculations for pediatric medications.
Eliminate system- or task-induced errors, such as
poor labelling and inconspicuous display of the
decimal place.
Double-check with another colleague and seek
guidance if you are in doubt about whether a dose
is correct.
Ensure that drug protocols and practice guidelines
are kept up to date.
The independence of double-checking systems is
crucial. In some situations, not all double checks are
truly independent, although the checks are performed
independently by separate practitioners.* This problem
stems from both endogenous and exogenous errors.
Endogenous errors arise within the mind of an individual;
thus, endogenous errors made by one person will be
independent of endogenous errors made by another.
Double checks therefore have their utmost effect in
preventing endogenous errors. If an error is exogenous,
arising from characteristics of the task or a poor display
of numbers and decimal places, there is a high
probability that the 2 individuals doing the checking will
make the same error. In many cases, such system-
or task-induced errors may also entail the psychological
phenomenon called confirmation bias, whereby a
person reading a medication label sees what he or she
expects to see, rather than what is actually printed there.
Dr Anthony Grasha has echoed that the most important
issue in making double-checking effective is the
elimination of task-induced factors from the work
environment, e.g., computer screens that do not show
decimal points well, letters and numbers that are not well
defined, and poor contrast in visual displays.
Double-check policies are instituted at the discretion
of individual hospitals and pharmacies, and none of the
regulatory bodies for pharmacists have enforced double-
checking criteria. However, the College of Pharmacists of
British Columbia does have standards for pharmacy
technicians for checking both sterile and nonsterile
products. These standards hold the pharmacist account-
able for ensuring that a verification process is in place.
3
Similarly, the Ontario College of Pharmacists is working
on a standard for certified technicians for checking
compounded pharmaceutical preparations. In addition,
many colleges require that pharmacists have dialogue (or
counselling) with the patient for all new prescriptions.
One of the benefits of such dialogue is that the patients
may provide another check in the process by reviewing
their own medications.
Given the ever-increasing workload of pharmacists,
shrinking resources, and pharmacist shortages,
performing a double check can be tall order for many
pharmacies. While we are making improvements in
other systems and eliminating task-induced errors, we
should use our professional discretion and apply double-
checking for selected high-risk patient populations and
selected high-alert drugs. The Insitute for Safe
Medication Practices (ISMP) provides a list of high-alert
drugs at its Web site (www.ismp.org).
[References are listed on page 169.]
SPECIAL FEATURE
The special feature presented below is taken directly from
ISMP Medication Safety Alert! volume 8, issue 5,
March 6, 2003.
The Virtues of Independent Double Checks
They Really Are Worth Your Time!
Has your double check system ever failed, leading
to a medication error that escaped your detection and
ultimately reached a patient? If you answered yes to
this question, youre not alone. Heres one recent
example. A pharmacist correctly calculated the dose and
volume of interferon for an infant, but entered 0.68 mL
*John Senders, Professor Emeritus, University of Toronto,
Toronto, Ontario. Personal communication April 1, 2003.
Anthony Grasha, Professor of Psychology, University
of Cincinnati, Cincinnati, Ohio. Personal communication
April 17, 2003.
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into the computer instead of the correct volume of 0.068
mL (a common mistake documented in the literature). A
second pharmacist double checked the calculation. He
arrived at the correct volume of 0.068, but misread the
computer entry of 0.68 by the first pharmacist as 0.068
due to confirmation bias seeing only what one expects
to see and overlooking any disconfirming evidence.
As this example shows, theres no question that
double checks carried out by people fail at times. But
have these failures led you to doubt the overall value of
double check systems? Given how busy healthcare
professionals are, do you wonder if this error reduction
strategy is even worth your time to carry out? We asked
Dr Anthony Grasha, Professor of Psychology at the
University of Cincinnati, to offer comment on this issue.
Research shows that people find about 95% of all
mistakes when checking the work of others.
4,5
Mathematically, the benefit of double checks can be
demonstrated by multiplying this 5% error rate during
the checking process and the rate in which errors occur
with the task itself (the checking error rate x the task
error rate). For example, if a pharmacy dispensing error
rate is 5% (based on research findings), and a double
check occurs before medications are dispensed, then
the actual chance of a dispensing error reaching the
patient is 5% of 5%, or only 0.25%.
Human factors suggest that double checks are more
effective if they are performed independently. For
example, an error in the concentration of a drug will be
detected more often if the person checking the product
performs all calculations independently, without
knowledge of any prior calculations. In fact, sharing
prior calculations or performing a double check
together with the person who originally completed the
task is fraught with problems. In these instances, if a
mistake is present, the person checking the work is
more easily drawn into the same mistake, especially if
it appears to be correct at first glance (e.g., numbers
correct but decimal point placement wrong, correct
drug but wrong concentration selected during PCA
[patient-controlled analgesia] pump set-up).
Dr Grasha also points out that the effectiveness of
double check systems depends on training staff to carry
them out properly as an independent cognitive task,
not a superficial routine task. And with workload issues
looming heavily over practitioners, double checks
should only be applied strategically to situations that
most warrant their use prescribing, dispensing, and
administering select high alert medications. These have
the greatest chance of harming patients if misused.
Fewer well-placed double checks will be much more
successful than an overabundance of double checks.
References
1. Jarman H, Jacobs E, Zielinski V. Medication study supports
registered nurses competence for single checking. Int J Nurs Pract
2002;8:330-5.
2. Kozer E, Scolnik D, Macpherson A, Keays T, Shi K, Luk T, et al.
Variables associated with medication errors in pediatric emergency
medicine. Pediatrics 2002;110:737-42.
3. Standards for pharmacy technician verification of sterile products.
Vancouver (BC): College of Pharmacists of British Columbia;
2000 Apr.
4. Grasha AF, Reilley S, Schell KL, Tranum D, Filburn J. Process and
delayed verification errors in community pharmacy: implications for
improving accuracy and patient safety. Technical Report 112101.
Cincinnati (OH): Cognitive-Systems Performance Laboratory; 2001.
5. Campbell GM, Facchinetti N. Using process control charts to
monitor dispensing and checking errors. Am J Health Syst Pharm
2000;55:946-52.
David U, MScPhm, is President and CEO, Institute for Safe
Medication Practices Canada (ISMP Canada).
e-mail: [email protected]
ISMP Canada home page: www.ismp-canada.org