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PSNet: Patient Safety Network
Journal Article

A randomized controlled trial on the effect of a double check on the detection of medication errors.

Douglass AM, Elder J, Watson R, et al. Ann Emerg Med. 2018;71(1):74-82.e1.

The use of double checks by two nurses is a strategy to minimize the risk of medication administration error. This randomized controlled trial investigated the effectiveness of double checks in a simulated patient care scenario. The investigators found that double checking did increase rates of error identification compared to single checking, but many errors still went undetected. A prior qualitative study found that double checking is often variably implemented, with clinicians having differing perceptions on how to perform the process effectively.