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

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.