Annals of emergency medicine
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Randomized Controlled Trial
A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors.
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. ⋯ 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.