9.7.2 Double checking medicines: defence against error or contributory factor? (353)

Gerry Armitage, Senior Research Fellow, Quality & Safety Research Office, Bradford Institute for Health Research, Bradford, United Kingdom

Abstract:

Background:

The double checking of medicines in healthcare is a contestable procedure. It occupies an obvious position in healthcare practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. Using data from part of a larger study on the contributory factors in medication errors and their reporting, as well as the related psycho-social literature, double checking is re-appraised.

Aim:

To critically appraise the double checking process as a defence against drug error, and propose a systematic approach to improve communication between both parties.

Method:

Previous research studies are reviewed. Data are analysed from a review of 991 drug error reports; and a subsequent series of 40 in-depth interviews with volunteer health professionals in an acute hospital in Northern England in Summer 2005. The interview schedule was informed by the preceding report analysis, and the data analysis informed by Spencer et al (2003) to ultimately form coded categories.

Results:

The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent, four key categories were apparent: deference to authority, reduction of responsibility, automatic processing, and lack of time. Participants also offered solutions to the problems which are discussed with several recommendations.

Discussion & conclusion:

Double checking medicines should be a selective, systematic procedure informed by key principles and encompassing certain behaviours (Armitage 2007). Psychological research may be instructive in reducing checking errors, and crew resource management, as practiced by the aviation industry, could increase error wisdom.

Biography:

Gerry Armitage worked as a registered nurse for 13 years in both junior and senior posts. Following this he spent a similar length of time working in higher education where he led pre and post registration nursing programmes and developed new courses with the NHS, independent sector, and outside the UK. He recently completed a 3 year research study funded by the Department of Health which culminated in the introduction of a drug error reporting system for an acute hospitals trust. He is currently leading a study funded by the Parkinson’s Disease Society to examine the quality of care planning in residential care, including medicines management. He is also leading a multi-disciplinary research team in evaluating the role of electronic health records in reducing prescribing errors on acute admission to elderly care. He has published in the field of child health, drug errors and incident reporting.