Single and Safe Intervention for MEDication administration (SaSI-MEDs): The development and evaluation of an intervention to de-implement unnecessary double-checking of medicines in hospital - Yorkshire Quality and Safety Research Group

Home » OUR RESEARCH » Single and Safe Intervention for MEDication administration (SaSI-MEDs): The development and evaluation of an intervention to de-implement unnecessary double-checking of medicines in hospital

Overview

Double checking of medication is normal practice for many medicines in the UK, particularly controlled drugs which is a mandatory process. However, there is no legal requirement for this to happen with non-controlled drugs, although many trusts require certain drugs to be double checked as part of their medicines policy.

Around 130,000 medication mistakes happen every day in NHS hospitals. Most of these mistakes happen when medicines are being given to patients (e.g. wrong medicine, wrong dose, wrong patient). These errors are common and can harm patients and in rare cases, can lead to serious injury or death. ‘Double checking’ a medicine before giving it to the patient is often used to reduce medication errors. However, there is no convincing evidence that it works. Research on paediatric wards in Australia (Westbrook, 2021) showed nurses spent a lot of time double checking (6.4 minutes per check) which could actually cause harm to patients by causing delays to them getting critical medicines. Across the NHS, based on these findings, there could be an estimated to cost between £412 million and £1.28 billion each year.

If double-checking clearly improved patient safety, this time and cost might be worthwhile. But evidence suggests that double-checking is often not carried out properly, may not work as intended, and can sometimes even contribute to harm. Because of this, nurses’ time might be better used on other safety activities that more effectively improve patient care.

In 2022, NHS England identified the question “Does double-checking medicines reduce errors?” as a national research priority. Our study aims to answer this question.

The NIHR Yorkshire and Humber Patient Safety Research Collaboration, were awarded funding to research this question. We have worked with patients and healthcare staff to better understand the issue and how often double-checking is used. We found that double-checking medicines is common in hospitals across England, although only a few hospitals have tried to reduce or stop the practice. Both staff and patients agreed that reducing low-value care is important for improving modern healthcare.

This work is split into 5 smaller projects detailed below.

This work package involved two phases. The first phase, 1a, explored six services across three NHS Trusts that had different experiences of double-checking and different approaches to changing this practice. The second phase, project1b, used findings from this work, together with other sources of information, to co-design an intervention to reduce or stop double-checking.

Patients and healthcare staff have helped us design and improve this intervention, as well as test how it can best be introduced in hospitals and what effects it has. The intervention is called Safe Administration of Medicines – Intervention (SAM-I), and we will start testing it in 3 Hospital Trusts in September 2026.

This project is currently examining the who, what, when and where of double-checking practice. It will also define and describe the consequences of double-checking in relation to medication errors, staff time, and delays in medication administration. This will be the first study in England to provide a detailed description of double-checking processes and outcomes. Reported medication administration errors and associated harm will also be analysed in detail.

This project has involved the same three Trusts included in project 1. As previously described, these Trusts were selected to provide variation in size, urban and rural populations, and teaching hospital status. However, the selection of services within this phase of the project has differed, as we have not observed services where double-checking has already been discontinued or where there has recently been an initiative to stop double-checking.

We will carry out a non-randomised feasibility study. This study will help us understand whether the intervention can be delivered in practice and how it works in real-world settings. It will also allow us to make changes to the intervention or the way it is implemented, and to test the processes needed before a larger main trial takes place.

In a fully powered trial (≈21 months), we will establish if stopping double-checking of medicines in hospital is non-inferior in terms of medication administration errors and patient harm and is superior in terms of reducing nursing costs and delays in medication administration.

This involves first conducting a stakeholder analysis to identify people who have both an interest in, and influence on, the policy and practice of double-checking. Stakeholders are likely to include policy makers, regulators, Healthcare Safety Investigation Branch chief investigators, Royal Colleges, NHS England medication safety lead, patient leaders, nurses, patient safety specialists and medication safety officers. In anticipation of this research programme, we have already established a relationship with the Medication Safety Officers group, attending two meetings in the run up to this application to introduce the study concept and to get their input to study design. They have expressed a strong interest in supporting this work and we will continue to engage with them throughout the programme. Clinical Improvement Lead for the Medicines Safety Improvement Programme at NHS England (Tony Jamieson) has agreed to sit on our independent steering committee. While some stakeholders will be directly involved in the intervention development or the steering committee, we will also bring together other external stakeholders (e.g. regulators and policy makers) above to provide a letter of support to all Trusts who choose to participate in the study. This, we anticipate, will allay fears that nurse and pharmacy managers have expressed about the repercussions of moving to a single-check of medicines.