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Qual Saf Health Care. 2010 Dec;19(6):562-7. doi: 10.1136/qshc.2009.032862. Epub 2010 Aug 19.

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

Author information

  • 1Healthcare Human Factors Group, Centre for Global eHealth Innovation, University Health Network, Toronto, Canada. rachel.white@uhn.on.ca

Erratum in

  • Qual Saf Health Care. 2011 May;20(5):396.

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.

PMID:
20724398
[PubMed - indexed for MEDLINE]
PMCID:
PMC3002832
Free PMC Article

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