Double-checking in the safe administration of medicines: Policy and practice in English hospitals

Abstract

Objectives

Double-checking medication administrations is one of the most frequently used strategies to prevent errors and associated harm. This practice is time-consuming, introduces repeated interruptions into the care process and lacks evidence of effectiveness. Double-checking is widespread in hospitals worldwide. In England, double-checking happens despite there being no regulatory requirement except for intravenous drugs and medicines that require complex calculations. Many hospital Trusts have assimilated double-checking over the past 25–30 years in response to recommendations from the investigation of medication administration errors. There is currently no national picture in England of the extent to which organisational policies stipulate double-checking, the variation in double-checking policy or how closely double-checking is perceived to be conducted in accordance with policies. This study set out to address these gaps in our understanding.

Methods

An online survey was distributed to a network of Medication Safety Officers (MSOs) and Freedom of Information requests were sent to 118 English NHS acute hospital Trusts for policies underpinning medicines administration. Data were analysed to address the research questions.

Results

Policies were received from 94 acute NHS Trusts (80% response rate) and 48 MSOs submitted a survey response (39% response rate). Double-checking policies vary considerably between Trusts. MSOs perceived that it is common in practice for double-checking not to be conducted in accordance with policy. All reviewed Trust policies required double-checking for controlled drugs. Further to this, many required double-checking for specific medicines or in particular circumstances. Most commonly, these were intravenous medicines, medicines administered to children, medicines requiring complex calculations and cytotoxic or chemotherapeutic medicines. However, policies varied considerably around administration of injectable medicines and insulin to adults. A minority of policies specified that ‘intravenous fluids’ needed to be double-checked. Most policies neither emphasised nor explained the importance of the independent nature of double-checking. There was also a great deal of variation between Trust policies in the medicines exempt from double-checking requirements.

Conclusions

The variation between policies identified by the present study might reflect a lack of robust evidence underpinning the practice of double-checking. Research is needed to understand if double-checking is effective at preventing medication errors and, if it is, the exact circumstances in which it is effective, to facilitate the standardisation of double-checking policies. Identifying circumstances in which double-checking is ineffective may justify the removal of some existing policies and could reduce nurse workload to free up time for patient-focused care.