Medication Safety and the Independent Double Check: A Work System Analysis and Reliability Engineering Theory Review

Abstract

Double checking is a standard practice in many areas of healthcare, despite the growing body of evidence suggesting that it is hard to do, and ineffective as a safety measure. We ask here: ‘What are the work system barriers that make IDC so ineffective?’ and, ‘What does the literature say about double-checking as a safety measure in sociotechnical systems?’