Leveraging single-checks to improve medication safety (23 July 2021)

Summary

An examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.

Content

Over the last five years, teams at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had completed at least four different improvement projects focused on increasing adherence to the independent double check (IDC) process.

An IDC is when two registered nurses independently check a medication to ensure it is correct prior to administering it to the patient. Like other institutions, the hospital did not require this process for all medications but did require it for a select group of medications considered higher risk if given in incorrect doses, routes or times.

For years, the hospital examined and analysed the process and related policies for administering these medications, but with no appreciable change in medication error rates. The latest efforts included reducing the number of medications that required an IDC, which pleased the nursing staff, but still did not fix the issue.

Then, in the summer of 2019, a medication administration error in the PICU triggered yet another root cause analysis of the IDC process.

The frustration of repeated analyses and efforts led the team to take a different approach to investigating its practices. They leveraged the expertise of a resident human factors practitioner—an expert in evaluating the interactions of people, tasks, the environment and technology—to lead the analysis.

The root cause analysis team, in partnership with the human factors practitioner, was tasked with understanding the PICU’s IDC practice and what might be done to strengthen it. Little did they know their investigation would lead them to ask broader and different questions about IDC than they could have imagined.

They went from wondering how to do an IDC better to wondering why they were a good idea in the first place. This realisation came from examining unsatisfactory data and misguided theories on how humans interact with their work environment and each other.

The project’s outcomes show support for alternatives to safely administering medications without using IDCs. It can be difficult to challenge the status quo. But don’t forget the importance of looking at data rather than relying on processes that exist simply because that’s the way they’ve always been done.