Double checking medicines: defence against error or contributory factor?

J Eval Clin Pract. 2008 Aug;14(4):513-9. doi: 10.1111/j.1365-2753.2007.00907.x.


Rationale and aim: The double checking of medicines in health care is a contestable procedure. It occupies an obvious position in health care practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. This paper presents an appraisal of the process using data from part of a larger study on the contributory factors in medication errors and their reporting.

Methods: Previous research studies are reviewed; data are analysed from a review of 991 drug error reports and a subsequent series of 40 in-depth interviews with health professionals in an acute hospital in northern England.

Results: The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent. Four key categories were apparent: deference to authority, reduction of responsibility, automatic processing and lack of time. Solutions to the problems were also offered, which are discussed with several recommendations.

Conclusions: Double checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours. Psychological research may be instructive in reducing checking errors but the aviation industry may also have a part to play in increasing error wisdom and reducing risk.

MeSH terms

  • Hospitals, Teaching / organization & administration
  • Humans
  • Incidence
  • Medication Errors / prevention & control*
  • Pharmacy Service, Hospital / organization & administration*
  • Risk Management / organization & administration*
  • Time Factors