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      Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM


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          Double-check protocol compliance during administration is low. Regardless, most high-risk medication administrations are performed without incidents. The present study investigated the process of preparing and administrating high-risk medication and examined which variations occur in daily practice. Additionally, we investigated which considerations were taken into account when deviating from the guidelines.


          Ten Dutch hospital wards participated. The Functional Resonance Analysis Method was applied to construct a model depicting the Dutch guidelines and a ward-overarching model visualizing daily practice. To create the ward-overarching model, eight semi-structured interviews were conducted per ward discussing the preparation and administration of high-risk medication. Work related Efficiency-Thoroughness Trade-Off rules were used to structure subconscious considerations.


          In total, 77 nurses were interviewed. Six model deviations were found between the guideline model and ward-overarching model. Notably, four variations in double-check procedures were found. Here, time pressure was an important factor. Nurses made a risk-assessment, considering for patient stability, and difficulty of calculations, to determine whether the double-check would be executed. Additionally, subconscious reasonings, such as trusting their own or colleagues expertise, weighed on the decision.


          Time pressure is the most important factor that withholds nurses from performing the double-check. Nurses instead conduct a risk-assessment to decide if the double-check will be executed. The double-check can thus become habitual or unnecessary for certain medications. In future research, insights of the FRAM could be used to make ward-specific alterations for the double-check procedure of medications, that focus on feasibility in daily practice, while maintaining patient safety.


          • Four variations have been found in double-check procedures of nurses.

          • Nurses make a risk-assessment to determine if the double-check will be performed.

          • Our findings showed the double-check guidelines are not feasible in daily practice.

          • Develop ward-specific alterations that focus on feasibility to enhance safety.

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          What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

          Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.
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            Causes of intravenous medication errors: an ethnographic study.

            Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory. A trained and experienced observer accompanied nurses during IV drug rounds on 10 wards in two hospitals (one university teaching hospital and one non-teaching hospital) in the UK. Information came from observation and talking informally to staff. Human error theory was used to analyse the causes of IV error. 265 IV drug errors were identified during observation of 483 drug preparations and 447 administrations. The most common type of error was the deliberate violation of guidelines when injecting bolus doses faster than the recommended speed of 3-5 minutes. Causes included a lack of perceived risk, poor role models, and available technology. Mistakes occurred when drug preparation or administration involved uncommon procedures such as the preparation of very small volumes or the use of unusual drug vial presentations. Causes included a lack of knowledge of preparation or administration procedures and complex design of equipment. Underlying problems were the cultural context allowing unsafe drug use, the failure to teach practical aspects of drug handling, and design failures. Training needs and design issues should be addressed to reduce the rate of IV drug preparation and administration errors. This needs a coordinated approach from practitioners, regulators, and the pharmaceutical industry.
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              Incidence and severity of intravenous drug errors in a German hospital.

              To determine the incidence of errors in preparing and administering intravenous (i.v.) drugs, identify the stages in the process at which errors occurred and evaluate their clinical importance. A prospective ethnographic study using disguised observation was carried out on two wards in one German non-university hospital. We observed 22 nurses administering 122 i.v. drug preparations and administrations. One or more errors occurred in the preparation and administration of 58 of 122 i.v. drug doses (error rate 48%, 95% confidence interval 39-57%). In total, 65 errors were identified. Of doses, 4 had potentially severe errors (3%), 38 (31%) potentially moderate errors and 16 (13%) potentially minor errors. Common errors included multiple step preparations and the co-administration of potentially incompatible drugs as intermittent infusions. A high incidence of i.v. drug errors was found in the study hospital. Effective strategies to reduce potentially harmful errors are urgently needed. Measures could include a reduction in the number of ward-based i.v. drug preparations, improvement of staff training and the introduction of ward-based clinical pharmacy services.

                Author and article information

                01 February 2024
                29 February 2024
                01 February 2024
                : 10
                : 4
                : e25637
                [a ]Netherlands Institute for Health Services Research (Nivel), Organization and Quality of Care, Utrecht, the Netherlands
                [b ]Amsterdam Public Health Research Institute, Department of Quality of Care, Amsterdam, the Netherlands
                Author notes
                []Corresponding author. s.a.vanstralen@ 123456amsterdamumc.nl
                S2405-8440(24)01668-2 e25637
                © 2024 Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                : 13 June 2023
                : 26 January 2024
                : 31 January 2024
                Research Article

                patient safety,double check,work-as-imagined,work-as-done


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