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Original research
What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies
  1. Yvonne Pfeiffer1,
  2. Chantal Zimmermann2,
  3. David L. B. Schwappach1,2
  1. 1Swiss Patient Safety Foundation, Asylstr, Zurich, Switzerland
  2. 2Institute of Social and Preventive Medicine (ISPM), University of Bern, Zurich, Switzerland
  1. Correspondence to Dr Yvonne Pfeiffer; pfeiffer{at}


Objectives Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies.

Design In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy.

Setting Oncological wards and ambulatory infusion centres of three Swiss hospitals.

Participants Nurses’ double checking was observed.

Outcome measures In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers.

Results In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions.

Conclusions In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process.

  • chemotherapy
  • quality in health care
  • organisation of health services

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  • Contributors The study was designed by DS and YP. Data analysis was undertaken by YP and CZ. Data interpretation was undertaken by YP and DS. The draft manuscript was written by YP. DS and CZ revised the manuscript for important intellectual content. All of the authors have read, revised and approved the final manuscript.

  • Funding This work was supported by a research grant from Krebsforschung Schweiz (Cancer Research Switzerland, Grant No. KFS-3496-08-2014) and by an unrestricted research grant from the Hanela-Stiftung.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the 'Methods' section for further details.

  • Patient consent for publication Not required.

  • Ethics approval The study was considered exempt by the Cantonal ethics committee (KEK ZH Nr. 2016–00094), as data assessment was anonymous, and no patient-related data were gathered.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. The datasets generated and analysed during the current study are not publicly available due to protecting participant confidentiality.

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