Every day in NHS hospitals there are approximately 130,000 medication errors. Over three quarters of these errors happen while giving medicines to patients (medication administration errors). These errors, such as giving the wrong dose or medicines to the wrong patients, occur frequently and can harm patients. In very rare cases, errors cause severe harm or death. Strategies to reduce errors include double-checking. Here, two registered nurses check that the medicine is the right one for the patient and that the dose is correct, before giving the medicine.
At the moment, there is no convincing evidence that double-checking reduces medication administration errors. Research has also found that double-checking can harm patients because it leads to delays in patients getting critical medicines. Also, because nurses spend so much time on this activity (6.4 minutes per check), double-checking has been estimated to cost the NHS between £412 million and £1.28 billion per year. If double-checking reduced patient harm then this might be time well spent by nurses (cost-effective). But, the evidence suggests that double-checking is conducted incorrectly, may not work as intended and can, itself, harm patients. So, nurses’ time could be better spent doing other tasks that improve patient outcomes, such as other safety-focused work.
Impact of double-checking medicines on patients and service
In 2022 NHS England said that knowing whether ‘double-checking medications reduces errors’ was a national research priority. Our aim is to answer this research question. Before applying for the funding to do this work, we (the NIHR Yorkshire and Humber Patient Safety Research Collaboration) worked with patients and clinical staff to understand this problem and the prevalence of double-checking. Double checking was found to be prevalent across hospitals in England with only localised attempts to reduce or stop this practice. Both staff and patients agreed that reducing low-value care is a priority for modern healthcare and research.
In our first two years we will, we will use a range of methods, including observation, interviews and an analysis of NHS documents to understand current practice of double-checking medicines in English hospitals. We will then use this knowledge and current research evidence to develop a set of actions (intervention) to encourage nurses to stop double-checking. We will work with patients and staff to develop this intervention and learn how best to deliver this intervention and what impact it has.
If this goes well, we will conduct an experiment in 28 hospital services, comparing those that receive the intervention to help them stop-double checking with those that do not. Every service gets the intervention at some point. This trial will find out whether stopping double-checking of medicines saves money without increasing patient harm. We will also explore how the intervention works in different hospital services. We will work with our network of stakeholders, patient and staff representatives throughout and share findings through reports, publications, conferences and other creative methods.