Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach.
J Patient Saf
; 20(3): 209-215, 2024 Apr 01.
Article
en En
| MEDLINE
| ID: mdl-38231892
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.
Texto completo:
1
Colección:
01-internacional
Banco de datos:
MEDLINE
Asunto principal:
Unidades de Cuidado Intensivo Pediátrico
/
Errores de Medicación
Límite:
Child
/
Humans
Idioma:
En
Revista:
J Patient Saf
Asunto de la revista:
SERVICOS DE SAUDE
Año:
2024
Tipo del documento:
Article