Independent Double Checks: Undervalued and Misused

A manual independent double check of high-alert medications is a strategy that has been widely promoted in healthcare to help detect potentially harmful errors before they reach patients. However, independent double checks used as a risk-reduction strategy have long been disputed as well as misused in healthcare.

• Its use has been a source of stress for busy prescribers, pharmacists, and nurses who are short on time.
• Its impact on safety has been questioned by those who rarely find mistakes during the checking process.
• Its inconsistent use and variability in how the task is carried out has rendered it incapable of detecting many errors.
• Its overuse as a risk-reduction strategy for high-alert medications has been called to task given its status as a weak error-reduction strategy, particularly if it is the only safeguard in place.
• Its frequent misuse as a quick fix for an ailing medication use system has been the bane of managers who have investigated serious errors that have reached a patient due to a failed double-check process.

Despite these challenges, the Institute for Safe Medication Practices believes that the selective and proper use of independent double checks can play an important role in medication safety.

Which medications does your organization require an independent double check? Does your organization limit the overuse of these checks?

Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.