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Independent double-checks for high-alert medications: Essential practice

Baldwin, Katrina BScN, RN; Walsh, Virginia MScN, RN

doi: 10.1097/01.NURSE.0000444547.64972.dc
Department: PATIENT SAFETY
Free

Ensuring independent double-checks for high-alert medications

Virginia Walsh is the former director of the surgical program and ICU at Hotel Dieu Grace Hospital in Windsor, Ontario, and an adjunct lecturer/sessional instructor (part-time) at the Faculty of Nursing of the University of Windsor, also in Windsor, Ontario. Katrina Baldwin is an RN on a medical unit at London Health Sciences Centre, University Hospital Site, in London, Ontario.

The authors acknowledge Dr. D. Rajacich, associate professor, and Dr. M. Freeman, assistant professor at the faculty of nursing, University of Windsor, for performing a peer review of this article.

The authors have disclosed that they have no financial relationships related to this article.

NURSES ARE RESPONSIBLE for ensuring the safe care of their patients. Conducting an independent double-check (IDC) when administering high-alert medications is one intervention used to ensure the patient receives medication in the safest manner possible. This article describes IDC's importance to patient safety and then addresses the barriers that nurses face in performing an IDC.

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What's an IDC?

According to the Institute for Safe Medication Practices (ISMP) and ISMP Canada, an IDC is a safety measure used to detect errors when administering high-alert medications.1,2 Although any medication error is potentially serious, the consequences of an error involving high-alert drugs can be especially devastating.3 Some examples of high-alert drugs are anticoagulants, chemotherapeutic agents, insulins, and opioids.

When an IDC is conducted, a second practitioner independently verifies that the dosage is correct; independently means without any input from the first practitioner. The second practitioner's answer is then compared with the first practitioner's results to verify that it's correct. The lack of collaboration is intended to eliminate the bias that would be created if the two practitioners jointly arrived at an answer and to reveal any errors.1,2

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Preventing errors

In its report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) found that 44,000 to 98,000 Americans die each year from medical errors.4 Similar results were found in Canada, with 9,250 to 23,750 Canadians dying each year as a result of a preventable adverse event.5 In response to these astonishing numbers, the IOM recommended that healthcare organizations develop a culture of safety that focuses on improving the reliability and safety of patient care.4

ISMP and ISMP Canada emphasize that mistakes in the healthcare setting will happen even when practitioners are doing their best because they're human and therefore fallible.1,2 Because human error is inevitable, changes within the system are needed to prevent errors from causing harm. IDCs need to be implemented to help lessen the number of mistakes that impact the patient and to improve patient safety overall.6 ISMP and ISMP Canada, along with the College of Nurses of Ontario (CNO), support the implementation of IDCs.1,7

Patients benefit from IDCs in various ways. When hospital staff have a more positive perception of patient safety culture, patients report a more positive experience with the care they received in the hospital.8 If nurses educate their patients about why IDCs are implemented, patients would have more trust in the nurses providing their care when they witness their nurses performing the procedure. This would in turn build a stronger nurse-patient therapeutic relationship, which might lead to more positive patient satisfaction outcomes.

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Are IDCs effective?

To date, little research has been conducted on IDCs' use or effectiveness in reducing medication errors among pharmacists and nurses. Present research supports the idea that IDCs are an effective patient safety strategy. Pharmacists, for example, were better at detecting their colleagues' errors than their own; this is attributed to confirmation bias, which is the tendency to see a result as correct rather than thinking that it may be wrong.6,9 A formal system in which two practitioners double-check completed prescriptions to reduce errors is recommended.

When conducted properly, IDCs catch about 95% of errors, leaving only a 5% chance of an error being missed.1,6 One research study noted that if the error rate for a process were 5% and an IDC policy were applied to this process, it would reduce the chance of an error to 5% of 5% or 0.25% (1 in 400).1,2 IDCs aren't foolproof, but when performed judiciously and properly, they reduce the risk of an error reaching the patient.1,6

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Understanding the hurdles

If IDCs are effective in preventing medication errors and ensuring patient safety, then why isn't this procedure being performed regularly? Here are a few key barriers.

  • Grissinger, a medication safety analyst at ISMP, notes that performing an IDC is time-consuming and nurses already face time constraints related to staffing shortages.6
  • In our experience, some nurses think that performing an IDC will lead to more errors; they believe that if they rely on their colleagues to catch problems, they won't be as diligent in checking their own work.
  • Some nurses don't perform an IDC because they “trust” their colleague's initial judgment.6

David U, President and CEO of ISMP Canada, has addressed a false sense of security among colleagues as a barrier to implementing a proper IDC.10 He reviewed pharmacists' practice of performing IDCs and noted increasing workloads, shrinking resources, and staffing shortages as some of the barriers to their performing IDCs. In the medication practice standard of care, the CNO does identify the need to enhance patient safety in medication administration. This is achieved by preventing errors by evaluating the need for IDCs or by conducting them.2 However, it's left to individual hospitals to develop a policy that outlines IDCs and their use for high-alert medication administration.

David U addresses the lack of a required standard for IDCs, adding that policies about IDCs are implemented at the discretion of individual healthcare institutions. Pharmacists, and in particular those who practice in community settings, have no regulatory body to enforce the IDC process.10

Nurses in the community should be guided by practice standards that improve patient safety, including IDC. They should follow licensing guidelines and their employer's policy and procedures.

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Tackling barriers

Research about ways of improving adherence with IDCs among nurses is scarce. ISMP Canada outlined four key points to help healthcare institutions implement an IDC system:2

  • Develop a policy and procedure that includes input from the staff carrying out IDCs.
  • Develop tools to help nurses follow an IDC policy and procedure without having to rely on memory or vigilance (for example, a checklist outlining the steps of a proper IDC).1
  • When teaching staff, emphasize that IDCs aren't implemented to question clinicians' competence; instead, they're a safety strategy to help mitigate the complexity of medication administration.
  • Address human factors engineering principles and their importance when implementing policies and tools regarding IDCs.2 (See What are the principles of human factors?)

ISMP encourages healthcare institutions to evaluate the procedures identified as requiring an IDC, monitor adherence among staff, assess how often the IDCs are being performed properly, and then make the changes needed to put a more successful and effective system in place.1

Norris stresses the application of human factors principles when addressing patient safety. Human factors are a way of designing systems to fit people instead of forcing people to fit the design of the system.11 Because human resources are required in the implementation of an IDC policy, applying Norris' principles may overcome some of the barriers nurses face and increase their adherence with the procedure.

Nurses need to actively participate in initiating changes that will help overcome the barriers they encounter in adhering to IDCs. One recommendation would be to educate nurses about the importance of implementing IDCs; for example, by providing statistics on the number of deaths occurring yearly because of medication administration errors and the impact that IDCs have on reducing these errors. Educating nurses and involving them in the integration of change into daily nursing practice will help ensure their adherence to any new procedure or policy.

At Ohio State University Medical Center, nurses on its 2-unit, 50-bed rehab department identified that not all staff were documenting the IDCs performed for insulin administration and collaborated to design a solution.12 They used a sticker that the nurse who performed the IDC would sign; the nurse administering the drug would place it in the patient's medical record to ensure the procedure was properly documented.

Before implementation of the sticker strategy, a review of flow sheets of patients with diabetes revealed that of 187 cases of insulin administration, only 65 (35%) double-checks were documented.12 Four weeks after initiating the sticker strategy, another review of these flow sheets revealed that of 230 cases of insulin administration, 167 (73%) double-checks were documented. A strong contributing factor to the success of the project was that the nurses collaborated to implement a procedure that worked for them.12

Through their advocacy and leadership, these nurses ultimately evolved into clinical champions for patient safety at their institution. According to Soo, Berta, and Baker, the presence of multidisciplinary front-line clinician champions is an additional driving force in the successful implementation of patient safety practice changes.13

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Critical patient safety step

IDCs are vital to the safe administration of medications and contribute to the delivery of safe patient care. Implementing IDCs and enhancing patient safety builds a stronger nurse-patient therapeutic relationship and leads to better patient outcomes. Implementing an IDC supports the nurse's duty to “do no harm.”4

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What are the principles of human factors?11,14

Human factors is a way of designing systems to fit people instead of forcing people to fit the design of the system, ensuring ease of use and reducing the potential for errors. These human factors principles apply to patient safety:

  • use participative design, which includes the user(s) in the design process
  • design for standardization and simplicity
  • design-in safety; that is, use technology safeguards that force the user to do the correct action and prevent the user from making a mistake
  • understand your users
  • know when and why things go wrong
  • make it easy for staff to do the right thing
  • advocate for safety
  • appreciate teamwork
  • think about how it all fits together
  • carry out change.
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REFERENCES

1. Institute for Safe Medication Practices. Independent double checks: undervalued and misused: selective use of this strategy can play an important role in medication safety. ISMP Medication Safety Alert! 2013;18(12). http://www.ismp.org/newsletters/acutecare/showarticle.asp?id=51.
2. Institute for Safe Medication Practices Canada. Lowering the risk of medication errors: independent double checks. ISMP Canada Safety Bulletin. 2005;5(1). http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005–01.pdf.
3. Institute for Safe Medication Practices. ISMP's list of high-alert medications. 2012. http://www.ismp.org/tools/highalertmedications.pdf.
4. National Research Council. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000.
5. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678–1686.
6. Grissinger M.The virtues of independent double-checks: they really are worth your time! Pharmacy & Therapeutics. 2006;31(9). http://pharmscope.com/ptJournal/fulltext/31/9/PTJ3109492.pdf.
7. College of Nurses of Ontario. Practice Standard: Medication. Rev. 2014. http://www.cno.org/Global/docs/prac/41007_Medication.pdf.
8. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients' assessments of hospital care. J Patient Saf. 2012;8(3):131–139.
9. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–780.
10. U D. Medication safety alerts. The Canadian Journal of Hospital Pharmacy. 2003;56(3):167–169. http://www.ismp-canada.org/download/cjhp/cjhp0304.pdf.
11. Norris B. Human factors and safe patient care. J Nurs Manag. 2009;17(2):203–211.
12. Hospodar M. Sticking together! A creative approach to documenting insulin double checks. Rehabil Nurs. 2007;32(1):6–8.
13. Soo S, Berta W, Baker GR. Role of champions in the implementation of patient safety practice change. Healthc Q. 2009;12(Spec No Patient):123–128.
14. Phansalkar S, Edworthy J, Hellier E, et al. A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems. J Am Med Inform Assoc. 2010;17(5):493–501.
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