The checking methods before medication administration: A perspective from a Joint Commission International–accredited academic medical center hospital in China

What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies

“…3 However, as two systematic reviews reported, the evidence supporting double checking as a safety increasing method is weak: the effectiveness of double checking procedures in reducing medication error rates and patient harm, i.e., in increasing medication safety has not yet been demonstrated empirically, 4 5 despite positive experiences being reported. [6][7][8] The aim of double checks applied in oncology often is to identify a potential inconsistency of information between two references: the order (as print-out or on a computer screen) and the actual drug (a label on an intravenous bag or a label on a bag or box of pills). An inconsistency means that for example the name, the dose or the day of administration on the drug label does not match the order.…”

“… 3 However, as two systematic reviews reported, the evidence supporting double checking as a safety increasing method is weak: the effectiveness of double checking procedures in reducing medication error rates and patient harm, i.e., in increasing medication safety has not yet been demonstrated empirically, 4 5 despite positive experiences being reported. 6–8 …”

What are we doing when we double check?

“…Currently, various checking procedures are covered under the umbrella term double checking14–16: for example, one nurse checking two times a prepared drug against the prescription, two nurses performing two checks sequentially or together, for example, one nurse reading aloud the prescription while the other nurse listens and checks the label and then in a second step reads back the label to the other nurse who checks against the prescription (read-read back procedure15). Another example for the missing clarity of the concept of double checking is that double checks have often been defined as requiring two persons,11 while single-person double-checking has also been proposed as a checking strategy 16. In order to systematise the various kinds of checking procedures, we developed the framework presented in the following.…”