Independent Double-Checking of High-Risk Clinical Procedures

Team
HumanEra
Timeline
December 2005 to December 2007

Summary

With a growing recognition that double-checking during high-risk clinical procedures provides an important additional measure of safety, many hospitals have adopted policies that specify independent double-checking for specific procedures. However, very little time has been spent guiding clinicians on the best approach.

The team used an experimental approach to examine what components of a double check contributed to effective detection of medication errors. Chemotherapy was chosen as the clinical model for this research given its high risk of patient safety.

The team started with observing 13 registered nurses in an outpatient chemotherapy unit to understand the context in which double-checking takes place and the specific risks associated with administering chemotherapy by ambulatory infusion pumps. The observations revealed that the existing form was not routinely used as intended because information was placed inconsistently with the nurses’ workflow with the pump. Also, nurses mostly ignored the instructions at the top of the form to check the patient’s armband to the medication label.

Based on the observations, the existing checklist was redesigned. Specifically, the checklist was rearranged so that it is consistent with the sequence of the pump prompts. Also, a specific item reminding the nurse to check the patient’s identify from the armband against the drug label was added to the checklist.

To compare the two checklists, the team simulated error checking for intravenous chemotherapy in the usability laboratory. Ten nurses from the outpatient chemotherapy unit participated in the testing. The study showed that checklists incorporating specific step-by-step instructions are useful for detecting certain errors, but are not failsafe.

Funding Agency

Canadian Patient Safety Institute

Project Sponsor

Tony Easty

 

Publications

White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. (2010). Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Quality and Safety in Health Care 2010;19(6):562-67.

http://www.patientsafetyinstitute.ca/English/research/cpsiResearchCompetitions/2005/Documents/Easty/Reports/Easty%20Full%20Report.pdf

 

White R, Savage P, Trip K, Ladak S, Hyland S, Colbert H, Tosine A, Incekol D, & Easty T (2008). A Study of Independent Double Checking Processes for Chemotherapy Administration via an Ambulatory Infusion Pump. Presented orally at the 15th annual International Conference on Cancer Nursing, Singapore, August 17-21, 2008.

White R, Savage P, Trip K, Ladak S, Hyland S, Colbert H, Tosine A, Incekol D, & Easty T (2008). Checking it Twice: Developing and Implementing an Effective Method for Independent Double-Checking of High-Risk Clinical Procedures. Presented orally at the Healthcare Systems Ergonomics and Patient Safety Conference, Strasbourg, France, June 25-27, 2008.

White, R. (2008). Implementing an Independent Double Check Checklist in a Chemo Clinic.Presented orally at the Institute for Safe Medication Practices Canada Medication Safety in Ontario Hospitals Conference, June 3, 2008.

White R, Savage P, Trip K, Ladak S, Hyland S, Colbert H, Tosine A, Incekol D, & Easty T. (2008) Checking it Twice: Evaluation of Two Double-Checking Methods for Opioid Infusion Devices in the Post-Anesthesia Care Unit.Presented orally at the Canadian Pain Society annual conference, Victoria, British Columbia, May 27-30, 2008.

White, R., Savage, P., Trip, K., Ladak, S., Hyland, S., Colbert, H., Tosine, A., Incekol, D., & Easty, A. (2008, Apr). Checking it twice: Developing and implementing an effective method for independent double-checking of high-risk clinical procedures. Poster presented at Celebrating Innovations in Health Care Expo, Toronto, Ontario.

White, R., Savage, P., Trip, K., Ladak, S., Hyland, S., Colbert, H., Tosine, A., Incekol, D., & Easty, A. (2007, Oct) Checking it twice: Developing and implementing an effective method for independent double-checking of high-risk clinical procedures. Poster presented at University Health Network Research Day, Toronto, Ontario.

Organizations

University Health Network (UHN)
ISMP Canada

Project Team

Rachel White
Patricia Trbovich
Heather Colbert
Raquel Lopez (student)

For more information about this project, contact:

Rachel White