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Identifying barriers and enablers for a robust independent second check of medication in adult intensive care

21 September 2023
Volume 32 · Issue 17



Independent second-checking of medication is part of everyday practice across many parts of the NHS. A robust, independent second check is built into medication administration protocols to reduce the risk of drug errors affecting patients.


This work aims to determine the barriers and facilitators regarding a robust independent second check of medication before administration to patients within adult critical care.


Nurses in adult critical care were invited to participate in focus groups. They were asked to discuss factors that they felt enabled or prevented a robust second check of medication. Thematic analysis was undertaken by three critical care pharmacists.


The major themes identified as barriers to an independent second check were: geography of the critical care unit; IT; routine; complex process; and personnel.


There are complex barriers to undertaking a robust second check and addressing some of these could improve patient safety.

Medication errors are a potential cause of harm to hospitalised patients. Medication error is an umbrella term that covers mistakes occurring at different stages of the complex process of prescribing, dispensing, preparation and administration. Many hospitals have policies mandating a double-check at specified stages of administration, with a view to improving safety by building in an opportunity for errors to be identified and rectified. These assume that there are no problems with having the resources to do so, including personnel or time constraints.

The process of double-checking involves two individuals independently assessing information and performing a set of actions in response to that information. This information may be in the form of written material (eg prescriptions and approved administration instructions) and be found on products themselves and include patient identity, as well as parameters such as allergy status on the patient's record. If double-checking is to be effective, it relies on two assumptions:

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