Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients (7 August 2020)

Summary

Double-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors.

The authors found that:

• most nurses complied with mandated double-checking, but the process was rarely independent
• when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking
• where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious.

They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.