Aims Double checking of medicine by two qualified nurses is implemented in paediatric practice to help prevent administration errors and is part of the medication policy for an Irish paediatric hospital.¹ A four-day audit was completed in January 2019 to determine the compliance of the paediatric intensive care unit (PICU) staff with the double-checking policy. The results of this audit were presented at the weekly Multi-Disciplinary Team risk huddle. Awareness and education followed. The aim was to establish a baseline of documentation rates for the co-signing of administered medicines using an electronic healthcare record in a PICU and to compare rates before and after awareness sessions.

Method In January 2019 for four non-consecutive days, the administration record for all patients on Floor one PICU were audited. This audit was repeated in July 2019. Using Philips® IntelliSpace Critical Care and Anaesthesia (ICCA), we counted the number of signatures for:

1. Medication administration (all PO and IV medicines).

2. Pump checks if required, according to the Standard Concentration Drug Library non-continuous table.

3. Continuous infusion preparation and pump programming.

4. Daily nurse handover checks.

Compliance was calculated by dividing the number of documented checks divided by the number of checks required for each medicine. Using Microsoft Excel® graphs showing compliance rates were determined and a Chi-Squared Test undertaken.

Results There were 39 patients included and 520 medicine orders for January, and 43 patients and 595 medicine orders for July.

1. There was an improvement of 8% in the co-signing for medication

2. Pump checks improved by 20%

3. Continuous infusions checks improved by 190%.

4. Handover checks improved by 100%

Conclusion The results show a clear improvement of the compliance of PICU nurses to the co-signing method described by the CHI medication policy. This study has established a baseline rate against which future audits can be measured.

Administration error detection rates can be improved with a double check.¹ Anecdotally in PICU medications are being second checked, however, documentation on the electronic health record is poor, because of various barriers encountered by the nursing staff (lack of access to computers, time consuming log in). We found that by creating awareness at our weekly risk huddle, documentation of second checks improved.

Double-checking has been shown to increase certain error detection rates in some circumstances, but not in others, especially if the age difference between the nurses is significant.² Moreover, additional studies that consider the time cost of using the double-check method the impact on other patients of the unit, and the effect on the health professionals’ vigilance are needed. Because the double check is time-consuming and has limitations, it may best be reserved for only the highest-risk medications. It is also important to identify the barriers to double-checking that nurses encounter, such as computer availability, time spent logging on and off, etc. Those barriers should be explored with PICU staff.

References

1. Alsulami Z, Conroy S, Choonara I. A systematic review of the effectiveness of double checking in preventing medication errors. Arch Dis Child. 2012;97:e2.

2. Douglass AM, Elder J, Watson R, et al. A randomized controlled trial on the effect of a double check on the detection of medication errors. Ann Emerg Med. 2018;71:74–82.e1.