What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies.

Pfeiffer, Yvonne; Zimmermann, Chantal; Schwappach, David L.B. (2020). What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies. BMJ open, 10(9), e039291. BMJ Publishing Group 10.1136/bmjopen-2020-039291

[img]
Preview
Text
Pfeiffer BMJOpen 2020.pdf - Published Version
Available under License Creative Commons: Attribution-Noncommercial (CC-BY-NC).

Download (305kB) | Preview

OBJECTIVES

Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.

DESIGN

In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.

SETTING

Oncological wards and ambulatory infusion centres of three Swiss hospitals.

PARTICIPANTS

Nurses' double checking was observed.

OUTCOME MEASURES

In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.

RESULTS

In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.

CONCLUSIONS

In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Pre-clinic Human Medicine > Institute of Social and Preventive Medicine (ISPM)

UniBE Contributor:

Schwappach, David

Subjects:

600 Technology > 610 Medicine & health
300 Social sciences, sociology & anthropology > 360 Social problems & social services

ISSN:

2044-6055

Publisher:

BMJ Publishing Group

Funders:

[52] Cancer Research Switzerland

Language:

English

Submitter:

Andrea Flükiger-Flückiger

Date Deposited:

24 Sep 2020 15:41

Last Modified:

13 Mar 2021 23:55

Publisher DOI:

10.1136/bmjopen-2020-039291

PubMed ID:

32948574

Uncontrolled Keywords:

chemotherapy organisation of health services quality in health care

BORIS DOI:

10.7892/boris.146623

URI:

https://boris.unibe.ch/id/eprint/146623

Actions (login required)

Edit item Edit item
Provide Feedback