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 MAEs | 133 (57.6%) | 1981 (59.5%) | 770 (66.3%) | 307 (73.8%) |
| MAEs | ||||
| Number of MAEs | 163 | 2387 | 427 | 121 |
| Mean (/100 administrations) | 71 | 72 | 37 | 29 |
| Potential harm severity† | ||||
| Minimum/minor | 67 (29%) | 974 (29.2%) | 314 (27.1%) | 78 (18.8%) |
| Moderate/serious | 31 (13.4%) | 377 (11.3%) | 77 (6.6%) | 31 (7.5%) |
| Patients | ||||
| Age, years (mean±SD) | 7.9±5.9 | 8.3±6.1 | 7.8±5.8 | 8.7±6.0 |
| Female gender | 125 (54.1%) | 1698 (51.0%) | 552 (47.6%) | 223 (53.6%) |
| Nurses | ||||
| Age, years | ||||
| 18–29 | 113 (48.9%) | 1550 (46.5%) | 483 (41.6%) | 176 (42.3%) |
| 30–39 | 49 (21.2%) | 707 (21.2%) | 271 (23.3%) | 78 (18.8%) |
| 40–49 | 39 (16.9%) | 661 (19.8%) | 298 (25.7%) | 128 (30.8%) |
| 50–59 | 24 (10.4%) | 317 (9.5%) | 88 (7.6%) | 24 (5.8%) |
| ≥60 | 6 (2.6%) | 97 (2.9%) | 21 (1.8%) | 10 (2.4%) |
| Female gender | 211 (91.3%) | 3118 (93.6%) | 1085 (93.5%) | 379 (91.1%) |
| Registered nurse | 193 (83.6%) | 2987 (89.7%) | 1161 (100%) | 416 (100%) |
| Years of experience | ||||
| 0–<2 | 48 (20.8%) | 590 (17.7%) | 212 (18.3%) | 110 (26.4%) |
| 2–<5 | 60 (26.0%) | 884 (26.5%) | 252 (21.7%) | 80 (19.2%) |
| 5–<10 | 45 (19.5%) | 610 (18.3%) | 171 (14.7%) | 43 (10.3%) |
| 10–<15 | 18 (7.8%) | 324 (9.7%) | 113 (9.7%) | 31 (7.5%) |
| 15–<20 | 17 (7.4%) | 314 (9.4%) | 144 (12.4%) | 43 (10.3%) |
| 20–<25 | 28 (12.1%) | 367 (11.0%) | 189 (16.3%) | 77 (18.5%) |
| ≥25 | 15 (6.5%) | 243 (7.3%) | 80 (6.9%) | 32 (7.7%) |
| Contextual factors | ||||
| On usual ward | 200 (86.6%) | 2690 (80.7%) | 1035 (89.2%) | 369 (88.7%) |
| Time of day | ||||
| 07:00–<10:00 | 80 (34.6%) | 1006 (30.2%) | 504 (43.4%) | 175 (42.1%) |
| 10:00–<14:00 | 52 (22.5%) | 734 (22.0%) | 282 (24.3%) | 104 (25.0%) |
| 14:00–<18:00 | 29 (12.6%) | 521 (15.6%) | 138 (11.9%) | 30 (7.2%) |
| 18:00–<22:00 | 70 (30.3%) | 1071 (32.1%) | 237 (20.4%) | 107 (25.7%) |
| Weekday | 197 (85.3%) | 2632 (79.0%) | 954 (82.1%) | 334 (80.3%) |
| eMM present on ward | 153 (66.2%) | 2042 (61.3%) | 645 (55.6%) | 173 (41.6%) |
| No. of interruptions | ||||
| 0 | 136 (58.9%) | 2031 (61.0%) | 846 (72.9%) | 302 (72.6%) |
| 1 | 57 (24.7%) | 785 (23.6%) | 219 (18.9%) | 82 (19.7%) |
| 2 | 23 (10.0%) | 296 (8.9%) | 62 (5.3%) | 23 (5.5%) |
| ≥3 | 15 (6.5%) | 220 (6.6%) | 34 (2.9%) | 9 (2.2%) |
| No. of multitasks | ||||
| 0 | 175 (75.8%) | 2692 (80.8%) | 931 (80.2%) | 369 (88.7%) |
| 1 | 37 (16.0%) | 429 (12.9%) | 168 (14.5%) | 38 (9.1%) |
| ≥2 | 19 (8.2%) | 211 (6.3%) | 62 (5.3%) | 9 (2.2%) |
| Parent at bedside | 202 (87.5%) | 2975 (89.3%) | 1062 (91.5%) | 374 (89.9%) |
| Administration route | ||||
| Oral | 156 (67.5%) | 2202 (66.1%) | 997 (85.9%) | 337 (81.0%) |
| Inhalation | 10 (4.3%) | 54 (1.6%) | 77 (6.6%) | 36 (8.7%) |
| IV infusion | 43 (18.6%) | 752 (22.6%) | 0 (0.0%) | 0 (0.0%) |
| IV injection | 17 (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.