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Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients
  1. Johanna I Westbrook1,
  2. Ling Li1,
  3. Magdalena Z Raban1,
  4. Amanda Woods1,
  5. Alain K Koyama1,
  6. Melissa Therese Baysari2,
  7. Richard O Day3,
  8. Cheryl McCullagh4,
  9. Mirela Prgomet1,
  10. Virginia Mumford1,
  11. Luciano Dalla-Pozza5,
  12. Madlen Gazarian6,
  13. Peter J Gates1,
  14. Valentina Lichtner1,7,
  15. Peter Barclay8,
  16. Alan Gardo9,
  17. Mark Wiggins10,
  18. Leslie White1
  1. 1Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  2. 2Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
  3. 3St Vincent's Hospital, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
  4. 4Executive, The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
  5. 5Cancer Centre for Children, Children's Hospital at Westmead, Westmead, New South Wales, Australia
  6. 6Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
  7. 7School of Pharmacy, University College London, London, UK
  8. 8Department of Pharmacy, Children's Hospital at Westmead, Westmead, New South Wales, Australia
  9. 9Nursing Department, Children's Hospital at Westmead, Westmead, New South Wales, Australia
  10. 10Department of Pyschology, Macquarie University, Sydney, New South Wales, Australia
  1. Correspondence to Professor Johanna I Westbrook, Centre for Health Systems and Safety Research, Macquarie University Australian Institute of Health Innovation, Sydney, NSW 2113, Australia; Johanna.westbrook{at}


Background Double-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades. While the practice is widespread, evidence of its effectiveness in reducing errors or harm is scarce.

Objectives To measure the association between double-checking, and the occurrence and potential severity of medication administration errors (MAEs); check duration; and factors associated with double-checking adherence.

Methods Direct observational study of 298 nurses, administering 5140 medication doses to 1523 patients, across nine wards, in a paediatric hospital. Independent observers recorded details of administrations and double-checking (independent; primed—one nurse shares information which may influence the checking nurse; incomplete; or none) in real time during weekdays and weekends between 07:00 and 22:00. Observational medication data were compared with patients’ medical records by a reviewer (blinded to checking-status), to identify MAEs. MAEs were rated for potential severity. Observations included administrations where double-checking was mandated, or optional. Multivariable regression examined the association between double-checking, MAEs and potential severity; and factors associated with policy adherence.

Results For 3563 administrations double-checking was mandated. Of these, 36 (1·0%) received independent double-checks, 3296 (92·5%) primed and 231 (6·5%) no/incomplete double-checks. For 1577 administrations double-checking was not mandatory, but in 26·3% (n=416) nurses chose to double-check. Where double-checking was mandated there was no significant association between double-checking and MAEs (OR 0·89 (0·65–1·21); p=0·44), or potential MAE severity (OR 0·86 (0·65–1·15); p=0·31). Where double-checking was not mandated, but performed, MAEs were less likely to occur (OR 0·71 (0·54–0·95); p=0·02) and had lower potential severity (OR 0·75 (0·57–0·99); p=0·04). Each double-check took an average of 6·4 min (107 hours/1000 administrations).

Conclusions Compliance with mandated double-checking was very high, but rarely independent. Primed double-checking was highly prevalent but compared with single-checking conferred no benefit in terms of reduced errors or severity. Our findings raise questions about if, when and how double-checking policies deliver safety benefits and warrant the considerable resource investments required in modern clinical settings.

  • medication safety
  • paediatrics
  • human factors

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Correction notice The article has been corrected since it was published online first. The co-author Madlen Gazarian's affiliation has been updated to Faculty of Medicine, University of New South Wales, Sydney, Australia.

  • Contributors JIW, LL, MZR, MTB conceived of and designed the study. AW, MZR, MP, MTB, PG, JIW provided specific input into the observational techniques and co-ordinated data collection. LL and AK analysed the data. CM, ROD, VM, MG, LD, PB, AG, LW supported nurse recruitment and provided specialist expertise in relation to nursing, medical and pharmacy practices, medications and hospital policies. VL and MW provided expertise in human factors. JIW drafted the manuscript. All authors contributed to the interpretation of results and provided review and approval of the final manuscript.

  • Funding This study was funded by European Union Horizon 2020 and grant number: Marie Sklodowska-Curie Fellowship (VL), National Health and Medical Research Council ( and grant number: Early Career Researcher Fellowship (MZR)1143941, Elizabeth Blackburn Leadership Fellowship (JIW)117, Partnership Project Grant (1094878) With Sydney Ch.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval was granted by Sydney Children’s Hospital Network Human Research Ethics Committee HREC/15/SCHN/370.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Study data cannot be obtained by a third party as a requirement of ethics approval.

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