Presentation
More is Not Always Better: Evaluating Quality and De-Implementation of Independent Double Checks for High Alert Medications
SessionApplied Methods (HE9)
DescriptionHospitals have universally been -performing high alert medication administration the same way-since about 2005. Independent Double Checks (IDCs) have long been prioritized as a safety measure to prevent errors. In the meantime, hospitals developed better systems to ensure safe administration of medications, such as barcoding medication administration. Recent research and a careful review of human factors and reliability theories suggest that IDCs add significant workload to nursing without always improving safety. We are working to simultaneously evaluate 1) the quality of existing IDCs and 2) trial removal of IDCs from selected medications.
To evaluate the quality of these IDCs in our 48-bed pediatric intensive care unit (PICU) and 26-bed cardiac intensive care unit (CICU) at Children’s Hospital Colorado, we implemented an improvement initiative. This quality improvement initiative focuses on enhancing patient safety through peer-to-peer nurse checkoffs, designed to evaluate and reinforce the practice of IDCs for continuous and intermittent high-alert medications. By implementing structured medication pump safety checks, nurses engage in real-time evaluations and collaborative learning and attempting to enhance medication administration practices. The pump check simulation included three continuous medications, two with errors, and one intermittent medication. The nurses were tasked to go through a pump check on all these medications, while we made note of any of the policy IDC steps that were missed. We then gave feedback about all the policy steps related to an IDC. The initiative aims to promote a culture of accountability and teamwork while reducing medication errors, ultimately improving patient outcomes, and nurse confidence in handling high-risk medications.
This quality improvement initiative identified critical gaps within our current process related to independent double checks for both continuous and intermittent high-alert medications. We uncovered inconsistencies in adherence to safety protocols and variations in the understanding and execution of these essential checks. Of note, a higher percentage of steps were missed than hypothesized.
Concurrent with the initiative on quality of the IDC process, we worked to evaluate de-implementation opportunities. We partnered closely with the Medication Safety Team to holistically evaluate safety mitigations for dispensing, preparing, administering, and monitoring of High Alert medications. As a result of this review, we have started strategically removing the requirement to perform an IDC with select medications – starting with oral/enteral digoxin, clobazam, clonazepam, and methadone. In 41 baseline observations for oral/enteral digoxin, we found that nurses had to interrupt the second nurse for an IDC in 33 observations (80%); of note, interruptions have been shown to reduce safety. Additionally, nurses left the room with the medication for IDC between scanning and administration 7 times (17%), which reduces the effectiveness of the highly reliable and computerized barcode medication administration. IDC takes an average of 3.3 minutes per administration, with high standard deviation (30 seconds – 7.5 minutes). There were no errors caught during this observation period, and only one error caught before reaching the patient in the 10 months since the IDC requirement was removed from oral/enteral digoxin. The 70 baseline observations for oral/enteral clobazam, clonazepam, and methadone were similar to those from oral/enteral digoxin, and the IDC requirement was removed from these drugs this past week (results pending).
While some high alert medications will no longer require or prompt for an IDC, we of course encourage nurses to get a double check if you would like one – the research suggests that voluntary IDCs are when that intervention is the most effective. We encouraged nurses to use their safety practices such as having a high-quality 7-rights medication checks and using barcode scanning before administration. Future work includes evaluating additional high alert medications for IDC de-implementation.
This is the first initiative we are aware of that have combined evaluations of quality improvement initiatives with a de-implementation study. Our work identified that the quality of IDCs current state is insufficient for catching medication errors. Simultaneously, removing IDC requirements from select high alert medications has not reduced safety. Therefore, this work demonstrates a shift in how we can think about widely accepted “safety” practices. It is challenging to de-implement a safety intervention, but careful evaluations can show examples of cases where hospitals can save time and effort while maintaining safety.
To evaluate the quality of these IDCs in our 48-bed pediatric intensive care unit (PICU) and 26-bed cardiac intensive care unit (CICU) at Children’s Hospital Colorado, we implemented an improvement initiative. This quality improvement initiative focuses on enhancing patient safety through peer-to-peer nurse checkoffs, designed to evaluate and reinforce the practice of IDCs for continuous and intermittent high-alert medications. By implementing structured medication pump safety checks, nurses engage in real-time evaluations and collaborative learning and attempting to enhance medication administration practices. The pump check simulation included three continuous medications, two with errors, and one intermittent medication. The nurses were tasked to go through a pump check on all these medications, while we made note of any of the policy IDC steps that were missed. We then gave feedback about all the policy steps related to an IDC. The initiative aims to promote a culture of accountability and teamwork while reducing medication errors, ultimately improving patient outcomes, and nurse confidence in handling high-risk medications.
This quality improvement initiative identified critical gaps within our current process related to independent double checks for both continuous and intermittent high-alert medications. We uncovered inconsistencies in adherence to safety protocols and variations in the understanding and execution of these essential checks. Of note, a higher percentage of steps were missed than hypothesized.
Concurrent with the initiative on quality of the IDC process, we worked to evaluate de-implementation opportunities. We partnered closely with the Medication Safety Team to holistically evaluate safety mitigations for dispensing, preparing, administering, and monitoring of High Alert medications. As a result of this review, we have started strategically removing the requirement to perform an IDC with select medications – starting with oral/enteral digoxin, clobazam, clonazepam, and methadone. In 41 baseline observations for oral/enteral digoxin, we found that nurses had to interrupt the second nurse for an IDC in 33 observations (80%); of note, interruptions have been shown to reduce safety. Additionally, nurses left the room with the medication for IDC between scanning and administration 7 times (17%), which reduces the effectiveness of the highly reliable and computerized barcode medication administration. IDC takes an average of 3.3 minutes per administration, with high standard deviation (30 seconds – 7.5 minutes). There were no errors caught during this observation period, and only one error caught before reaching the patient in the 10 months since the IDC requirement was removed from oral/enteral digoxin. The 70 baseline observations for oral/enteral clobazam, clonazepam, and methadone were similar to those from oral/enteral digoxin, and the IDC requirement was removed from these drugs this past week (results pending).
While some high alert medications will no longer require or prompt for an IDC, we of course encourage nurses to get a double check if you would like one – the research suggests that voluntary IDCs are when that intervention is the most effective. We encouraged nurses to use their safety practices such as having a high-quality 7-rights medication checks and using barcode scanning before administration. Future work includes evaluating additional high alert medications for IDC de-implementation.
This is the first initiative we are aware of that have combined evaluations of quality improvement initiatives with a de-implementation study. Our work identified that the quality of IDCs current state is insufficient for catching medication errors. Simultaneously, removing IDC requirements from select high alert medications has not reduced safety. Therefore, this work demonstrates a shift in how we can think about widely accepted “safety” practices. It is challenging to de-implement a safety intervention, but careful evaluations can show examples of cases where hospitals can save time and effort while maintaining safety.
Event Type
Oral Presentations
TimeWednesday, April 210:52am - 11:15am EDT
LocationHarbour C
Hospital Environments (HE)