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Is double-checking associated with lower medication error rates in paediatrics? Seminar – Thursday 18 August, University of Leeds

By 30th September 2022Previous Seminars

Medication administration errors (MAEs) are prevalent.  The use of double-checking as a strategy to prevent errors and associated harm in hospitals is internationally widespread. However, evidence of the effectiveness of this high-resource process is very limited. We conducted a direct observational study of medication administration to measure the association between double-checking and medication administration error rates.

The study was undertaken over 22 weeks during weekdays and weekends between 07:00 and 22:00 on nine wards at a major Sydney Children’s Hospital.  Hospital policy mandated an extensive list of medications requiring independent double-checking by two nurses. Trained clinical researchers observed 5,140 dose administrations by 298 nurses.

Specialised data collection software (Precise Observation System for Safe Use of Medicines – POSSUM) allowed observers to accurately collect multiple details of medication preparation and administration reliably. Steps in the double-checking process were defined and classified in terms of ‘primed’, ‘independent’ or ‘incomplete’ double-checking. Observational data of drugs administered were later compared to patients’ medication charts to identify any MAEs, by a researcher blinded to information about whether medications had been double-checked.  This presentation will report the results from this study and discuss implications for future work.


Professor Johanna Westbrook, PhD, FTSE, FAIDH, FACMI, FIAHSI, is internationally recognised for her research evaluating the effects of information and communication technology (ICT) in health care which has led to significant advances in our understanding of how clinical information systems deliver (or fail to deliver) benefits. She has led extensive studies on the impact of medication technologies in hospitals on medication safety and clinicians’ work. Her highly applied research has supported translation of this evidence into policy, practice, and IT system design changes. Johanna has contributed to theoretical models regarding the design of complex multi-method ICT evaluations. She led the development of the Work Observation Method by Activity Timing (WOMBAT) software to support the conduct of observational workflow studies. WOMBAT has been used in over 15 countries and version 3.0 is available in the Apple Store.

In 2019 she presented research findings to the Royal Commission into Aged Care Quality and Safety regarding the contribution that ICT can make to supporting improvements in monitoring the quality of care and outcomes in the sector.  Her work informed several of the recommendations in the Commission’s final report. She has several current projects in aged care including: the development of a National aged care medication roundtable; and a dashboard of predictive analytics for residential care.

Johanna’s interests centre around designing innovative approaches to delivering robust research evidence to inform translational improvements in the delivery and outcomes of health services. She has recently been working with a large health care provider to evaluate a large-scale organisational culture change intervention designed to reduce unprofessional behaviour between hospital staff.  This work has generated comprehensive new evidence of the scale and type of unprofessional behaviours occurring among over 5000 hospital staff in seven hospitals across three states.  Using an innovative multi-method research approach this project is delivering new information about mechanisms by which elements of the change program are effective, along quantitative data on changes in behaviours and attitudes 2-3 years after intervention implementation.

Johanna has >500 publications and been awarded >$70M in research grants. In 2014 she was named Australian ICT professional of the year. In 2020 she received the NHMRC Elizabeth Blackburn Investigator Award. Johanna has contributed to many policy bodies including being appointed to the inaugural Board of the Australian Digital Health Agency; Chair of the Deeble Institute Advisory Board, Australian Healthcare and Hospitals Association, and is a Co-Director for the Safety, Quality, Informatics and Leadership (SQIL) Program for the Harvard Medical School.