A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors.

STUDY OBJECTIVE: The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection. METHODS: Emergency department and ICU nurses worked in pairs to care for a simulated patient. Nurses were randomized into single- and double-check groups. Errors intentionally introduced into the simulation included weight-based dosage errors and wrong medication vial errors. The evaluator recorded whether a double check was used, whether errors were detected, and observational data about nurse behavior during the simulation. RESULTS: Forty-three pairs of nurses consented to enroll in the study. All nurses randomized to the double-check group used a double check. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0; 95% confidence interval 0.90 to 27.74). Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9; 95% confidence interval 1.0 to 408.5). CONCLUSION: Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error.

Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies.

OBJECTIVES: The objective was to determine the level of agreement between emergency physicians (EPs) and consulting psychiatrists in their diagnosis and disposition of emergency department (ED) patients with behavioral emergencies. METHODS: The authors conducted a prospective study at a university teaching hospital ED with an annual census of approximately 45,000 patients. During study hours, each time a psychiatric consultation was requested, the emergency medicine (EM) and consulting psychiatry residents were asked to fill out similar short questionnaires concerning their diagnoses and disposition decisions after they consulted with their attending physicians. EM and psychiatry residents were blinded to the other's assessment of the patient. Residents were asked about their evaluation of patients regarding: 1) psychiatric assessments, 2) if the patients presented a danger to themselves or others or were gravely disabled, and 3) the need for emergency psychiatric hospitalization. RESULTS: A total of 408 resident physician pairs were enrolled in the study. Patients ranged in age from 5 to 92 years, with a median age of 31 years; 50% were female. The most common psychiatric assessments, as evaluated by either EPs, consulting psychiatrists, or both, were mood disorder (66%), suicidality (57%), drug/alcohol abuse (26%), and psychosis (25%). Seventy-three percent were admitted for acute psychiatric hospitalization. Agreement between EPs and psychiatrists was 67% for presence of mood disorder, 82% for suicidality, 82% for drug/alcohol abuse, 85% for psychosis, and 85% for grave disability. There was 67% agreement regarding patient eligibility for involuntary psychiatric hold. EPs felt confident enough to make disposition decisions 87% of the time; for these patients there was 76% agreement with consulting psychiatrists about the final disposition decision. CONCLUSIONS: The 67% agreement between EPs and consulting psychiatrists regarding need for involuntary hold, and 76% agreement regarding final disposition, demonstrate a substantial disagreement between EPs and psychiatrists regarding management and disposition of ED patients with psychiatric complaints. Further studies with patient follow-up are needed to determine the accuracy of the ED assessments by both EPs and consulting psychiatrists.