Double-Checking of High-Risk Clinical Procedures

Issue
Over the past ten years, there has been a growing recognition that double-checking high-risk clinical procedures provides an important additional measure of safety. Double-checking is well established in other industries such as aviation, but is relatively new in the clinical healthcare setting. Many hospitals have adopted policies that specify independent double-checking for specific procedures, but very little time has been spent guiding healthcare clinicians on the best approach.

Methods
This research, funded by the Canadian Patient Safety Institute (CPSI), focuses on two specific high-risk scenarios; the delivery of chemotherapeutic agents, and the delivery of pain medications. The first phase consisted of observational studies on the existing activities of double-checking, to determine current practice. The second phase consisted of comparing different double-checking methodologies in a usability laboratory setting, to develop an optimum approach to independent double-checking. The final phase will be to pilot the newly developed methods in a clinical setting. We will share our findings widely with the healthcare community, through publications, ISMP Canada newsletters, and conference presentations. section to learn more about our services and case studies of our work.