Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA.
Yale University School of Medicine, New Haven, CT.
Ann Emerg Med. 2018 Jan;71(1):74-82.e1. doi: 10.1016/j.annemergmed.2017.03.022. Epub 2017 Jun 29.
The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection.
Emergency department and ICU nurses worked in pairs to care for a simulated patient. Nurses were randomized into single- and double-check groups. Errors intentionally introduced into the simulation included weight-based dosage errors and wrong medication vial errors. The evaluator recorded whether a double check was used, whether errors were detected, and observational data about nurse behavior during the simulation.
Forty-three pairs of nurses consented to enroll in the study. All nurses randomized to the double-check group used a double check. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0; 95% confidence interval 0.90 to 27.74). Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9; 95% confidence interval 1.0 to 408.5).
Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error.
提倡由两名护士进行双重检查，作为主要的差错预防策略。本研究旨在确定在使用高警示药物时，双重检查的使用频率，以及其是否能提高差错检出率。
急诊科和 ICU 的护士以两人一组的形式共同护理一位模拟患者。护士被随机分为单重检查组和双重检查组。在模拟中故意引入了两类错误：基于体重的剂量错误和错误的药物瓶错误。评估者记录是否进行了双重检查、是否检测到错误，以及在模拟过程中观察到的护士行为数据。
共有 43 对护士同意参与研究。所有被随机分配到双重检查组的护士都进行了双重检查。在单重检查组中，9%的护士检测到基于体重的剂量错误，而双重检查组中 33%的护士检测到了该错误（比值比 5.0；95%置信区间 0.90 至 27.74）。在单重检查组中，54%的护士检测到了错误的药瓶错误，而双重检查组中 100%的护士检测到了该错误（比值比 19.9；95%置信区间 1.0 至 408.5）。
我们的研究表明，护士在给予高警示药物前会使用双重检查。在某些情况下，使用双重检查会提高某些错误检测率，但在其他情况下则不然。两种方法都错过了许多错误。在某些情况下，第二位护士实际上阻止了第一位护士对错误采取行动。
