Journal Article

Effectiveness of double checking to reduce medication administration errors: a systematic review.

Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook JI. BMJ Qual Saf. 2019 Aug 7; [Epub ahead of print].

Medication administration errors are common and account for a significant fraction of medication errors. This systematic review examined the effect of medication double-checks on medication administration errors. Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence to double-checking protocols. Only one high-quality study showed improvement in medication administration error rates when a double-check took place. No studies demonstrated differences in patient harm with double-checking compared to usual medication administration practice. The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking medication administration confers a meaningful safety benefit. A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy for verifying the order prior to administration, which led to a medication administration error.