Table 1

Characteristics of medication administrations by double-checking status (n=5140)

Category and variable*Double-checking
mandatory
n=3563 (69.3%)
Double-checking
optional
n=1577 (30.7%)
Single-checked
(n=231)
Double-checked
(n=3332)
Single-checked
(n=1161)
Double-checked
(n=416)
No MAEs133 (57.6%)1981 (59.5%)770 (66.3%)307 (73.8%)
MAEs
 Number of MAEs1632387427121
 Mean (/100 administrations)71723729
Potential harm severity†
 Minimum/minor67 (29%)974 (29.2%)314 (27.1%)78 (18.8%)
 Moderate/serious31 (13.4%)377 (11.3%)77 (6.6%)31 (7.5%)
Patients
 Age, years (mean±SD)7.9±5.98.3±6.17.8±5.88.7±6.0
 Female gender125 (54.1%)1698 (51.0%)552 (47.6%)223 (53.6%)
Nurses
Age, years
 18–29113 (48.9%)1550 (46.5%)483 (41.6%)176 (42.3%)
 30–3949 (21.2%)707 (21.2%)271 (23.3%)78 (18.8%)
 40–4939 (16.9%)661 (19.8%)298 (25.7%)128 (30.8%)
 50–5924 (10.4%)317 (9.5%)88 (7.6%)24 (5.8%)
 ≥606 (2.6%)97 (2.9%)21 (1.8%)10 (2.4%)
Female gender211 (91.3%)3118 (93.6%)1085 (93.5%)379 (91.1%)
Registered nurse193 (83.6%)2987 (89.7%)1161 (100%)416 (100%)
Years of experience
 0–<248 (20.8%)590 (17.7%)212 (18.3%)110 (26.4%)
 2–<560 (26.0%)884 (26.5%)252 (21.7%)80 (19.2%)
 5–<1045 (19.5%)610 (18.3%)171 (14.7%)43 (10.3%)
 10–<1518 (7.8%)324 (9.7%)113 (9.7%)31 (7.5%)
 15–<2017 (7.4%)314 (9.4%)144 (12.4%)43 (10.3%)
 20–<2528 (12.1%)367 (11.0%)189 (16.3%)77 (18.5%)
 ≥2515 (6.5%)243 (7.3%)80 (6.9%)32 (7.7%)
Contextual factors
On usual ward200 (86.6%)2690 (80.7%)1035 (89.2%)369 (88.7%)
Time of day
 07:00–<10:0080 (34.6%)1006 (30.2%)504 (43.4%)175 (42.1%)
 10:00–<14:0052 (22.5%)734 (22.0%)282 (24.3%)104 (25.0%)
 14:00–<18:0029 (12.6%)521 (15.6%)138 (11.9%)30 (7.2%)
 18:00–<22:0070 (30.3%)1071 (32.1%)237 (20.4%)107 (25.7%)
Weekday197 (85.3%)2632 (79.0%)954 (82.1%)334 (80.3%)
eMM present on ward153 (66.2%)2042 (61.3%)645 (55.6%)173 (41.6%)
No. of interruptions
 0136 (58.9%)2031 (61.0%)846 (72.9%)302 (72.6%)
 157 (24.7%)785 (23.6%)219 (18.9%)82 (19.7%)
 223 (10.0%)296 (8.9%)62 (5.3%)23 (5.5%)
 ≥315 (6.5%)220 (6.6%)34 (2.9%)9 (2.2%)
No. of multitasks
 0175 (75.8%)2692 (80.8%)931 (80.2%)369 (88.7%)
 137 (16.0%)429 (12.9%)168 (14.5%)38 (9.1%)
 ≥219 (8.2%)211 (6.3%)62 (5.3%)9 (2.2%)
 Parent at bedside202 (87.5%)2975 (89.3%)1062 (91.5%)374 (89.9%)
Administration route
 Oral156 (67.5%)2202 (66.1%)997 (85.9%)337 (81.0%)
 Inhalation10 (4.3%)54 (1.6%)77 (6.6%)36 (8.7%)
 IV infusion43 (18.6%)752 (22.6%)0 (0.0%)0 (0.0%)
 IV injection17 (7.4%)226 (6.8%)0 (0.0%)0 (0.0%)
 Other‡5 (2.2%)98 (2.9%)87 (7.5%)43 (10.3%)
  • *Counts and proportions are shown for all variables unless defined otherwise.

  • †Each administration could have multiple errors. All MAEs were considered together for potential harm severity rating. Hence the totals of MAE and severity ratings will differ.

  • ‡Other includes ear, eye, nasal, rectal, subcutaneous injection, topical, transdermal, intramuscular injection.

  • eMM, electronic medication management system; MAE, medication administration error.