Do Collegial Double Checks Reduce Medication Administration Errors? Not Necessarily

by | Jun 28, 2018

Medication administration errors are a common fear for every nurse. As we drive home from a shift we ask ourselves “Did I calculate that drip and program the pump correctly?” and “Did I remember to give Room 5 his beta blocker?” Likely each one of us has called the unit upon arriving home to ask the next shift to double check the eMAR to reassure us that yes, we did administer the medication correctly.

Clearly nurses are stretched thin and on many days do not have enough time during a shift to perform all required tasks, much less spend quality time with our patients. There is often a lack of confidence that we are not treating our patients with the full care and attention that each one deserves – that we are increasing the risk of errors.

There’s a good reason for our concerns, as medication-related errors are the most frequent cause of harm to patients and account for 20 percent of all safety incidents.[1] Administration errors account for 38 percent of medication errors, about the same as the estimated 39 percent of errors related to medication ordering.[2] Unfortunately, nurses are often viewed as the last line of defense in preventing medication errors, even though working conditions and strategic organizational decisions – such as nurse staffing levels – often are the true causes of these errors.

Organizations often focus on two specific recommendations in an effort to help decrease the chances of medication errors – independent double checks (IDCs) and fewer interruptions when nurses are preparing and administering medications. However, there is an inherent conflict in those two directives.  How can nurses request IDCs while simultaneously decreasing interruptions? How can these two strategies co-exist?

IDCs vs. Interruptions

The Institute for Safe Medication Practices (ISMP) reports numerous studies have demonstrated that independent double checks may reduce the rate of medication errors by 95 percent.[3] So why don’t all nurses perform IDCs during the medication administration process? In time-constrained real-world scenarios, it’s not always easy to locate a colleague due to short-staffing. Some facilities have tried to impose IDCs by programming the eMAR with a “hard stop” that blocks documentation entry until a second nurse confirms review of the medication. But busy nurses sometimes devise workarounds such as scanning a colleague’s badge without the colleague actually checking the medication, or even photocopying badges that can be scanned when other nurses are not available for the double check.

There’s also evidence that collegial IDCs might not be as effective as we think. Studies have shown that humans make math errors three percent of the time. Under stressful conditions, that jumps to 25 percent and double check errors occur 10 percent of the time.

In order to find someone to perform an IDC in a chaotic environment, chances are you are interrupting another nurse from his or her own medication administration. The American Nurses Association says the chance of making a medication error increases by 12 percent with each interruption during a single administration episode. The rate doubles when four or more interruptions occur.[4] So in trying to solve one problem with IDCs are we creating a bigger problem with constant interruptions?

To try and combat the interruption issue, some hospitals have tried to create “no-interruption zones” by encircling the area around the medication cart with red tape or having the nurses don a yellow or red vest while administering medications to visually remind colleagues to not interrupt them. While a valiant attempt at solving the problem, this idea is just not practical in the real world and can seem almost silly in a busy hospital environment.

Consider if one colleague is in the “no-interruption zone” preparing medications while another colleague simultaneously needs an IDC. The second colleague is forced to wait outside the red tape for the first colleague while precious time passes. This process seems extremely inefficient and unrealistic. Considering the medication administration process takes nearly half of each nurse’s time per shift, it’s just not reasonable to expect that nurses can recruit their colleagues to perform these double checks at a time that isn’t considered an interruption. They will almost literally be bogged down by “red tape.”

Solving the problem

It’s clear that revising or adding to the nurses’ procedures is not enough to solve the problem. The answers must come from improved actions at the organizational level. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends establishing an organizational culture to minimize at-risk behaviors that may cause medication errors. At-risk behaviors emerge when healthcare providers are able to use shortcuts for convenience and to save time.

Though the nurse likely knows patient safety could be at risk, the perceived benefit is considered greater at that moment. This is a system-based problem and not an individual one. At-risk behaviors have been tolerated by organizations because they result in saved time or resources. Each organization should consider if nurses are being “punished” for safe behaviors by chastising them for spending extra time on tasks or for using additional resources. Consider what causes staff to believe the positive rewards for at-risk behaviors outweigh any perceived drawbacks of the corresponding safe behaviors.

Each organization has a responsibility to eliminate tolerance of risk, even if this requires investing money on technological support for the nurses, hiring additional staff, or decreasing workloads. To communicate a culture of safety to all staff, the organization must fully support patient safety with realistic solutions.

Asking nurses to perform double checks without interrupting each other is obviously nearly impossible. Nurses are hardworking professionals that often achieve miraculous things, but even they can’t accomplish those mutually exclusive tasks. Hiring more nurses to stand around to just perform double checks is not financially feasible. Hospitals must find other fixes to improve the system – such as leveraging rapidly improving technology tools – to help solve the problem. Only then will we be on the road to truly improving medication administration safety.

[1]Effectiveness of interventions to prevent medication errors: An umbrella systematic review protocolby S. Hines, K. Kynoch, and H. Khalil. JBI Database of Systematic Reviews and Implementation Reports, 2018.

[2]Assessment of the nurse medication administration workflow processby N. Huynh, R. Snyder, J. M. Vidal, O. Sharif, B. Cai, B. Parsons, and K. Bennett. Journal of Healthcare Engineering, 2016 (article ID 6823185).

[3]Independent double checks: Undervalued and misused: Selective use of this strategy can play an important role in medication safety. Institute for Safe Medication Practices (2013).

[4]Preventing high-alert medication errors in hospital patients by P. Anderson and T. Townsend, American Nurse Today (2015).