Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach

Abstract

Objectives The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process. Methods The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications, (2) hospital length of stay, (3) patient mortality, (4) nurses’ favorability toward single checking, and (5) nursing time spent on administration of IDC medications. Results The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%–0.08%; P = 0.4939). The intervention also did not significantly alter mortality (P = 0.8784) or length of stay (P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes. Conclusions Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.