Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model

Abstract

Objective: To determine what components of a checklist contribute to effective detection of medication errors at the bedside.

Design: High-fidelity simulation study of outpatient chemotherapy administration.

Setting: Usability laboratory.

Participants: Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors.

Main outcome measures: Rates of specified types of errors related to medication administration.

Results: As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific step-by-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient's identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses' workflow had a positive impact on the ease of use and efficiency of the checklist.

Conclusions: Checklists designed with explicit step-by-step instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and abstract clinical problem solving.

Figure 1

Checklist for independent double checking introduced in the chemotherapy nursing unit (old checklist).

Figure 2

Redesigned checklist for performing double checks (new checklist).

Figure 3

Usability laboratory.

Figure 4

Nurse participant interacting with a patient actor as the confederate nurse interrupts in the simulated outpatient chemotherapy environment.

Figure 5

Error-detection rates by error type and checklist type.