Single and Safe Intervention for MEDication administration (SaSI-MEDs): The development and evaluation of an intervention to de-implement unnecessary double-checking of medicines in hospital

Every day in NHS hospitals there are approximately 130,000 medication errors. Over three quarters of these errors happen while giving a medicine to a patient (medication administration errors) [1]. These errors, for example giving the wrong dose or a medicine to the wrong patient, occur frequently and can harm patients. In rare cases they lead to severe harm or death. Ways of attempting to reduce these errors include independent double-checking. Here, two registered nurses check (on their own) that the medicine is the right one for the patient and that the dose is correct, before giving the medicine.
There is no current evidence suggesting double-checking reduces medication administration errors [3]. Research has also found that double-checking can lead to delays in patients receiving critical medicines and requires considerable nurse time to do (6.4 minutes per check) [4]. Estimates of the annual cost to the NHS of double-checking range from £412 million to £1.28 billion as a result of nurse-time spent on this activity. If double-checking reduced patient harm then this might be time well spent by nurses (cost-effective). But, the evidence suggests that double-checking is very difficult to do, conducted incorrectly, may not work as intended and can itself harm patients. So, nurses’ time could be better spent performing other safety practices.
It is not surprising then that in 2022 NHS England said that knowing whether 'double-checking medications reduces errors' was a national research priority. To help answer this research question, we will encourage nurses to stop double-checking within a carefully monitored research study. This is an example of de-implementation - stopping doing something that is of low-value to patients - a topic that we are experts in. Over the past year, we have worked with patients and clinical staff and both groups think that de-implementation is a priority for modern healthcare and research. They also told us that a big challenge could be nurse anxiety about making errors.
Our research will use a range of methods, including observation, interviews and documentary analysis to understand current practice of double-checking medicines in English hospitals. We will work with patients and staff to develop a set of actions (an intervention) to reduce double-checking and then assess whether it is possible to deliver this intervention and collect data to evaluate its impact. If the answer is yes, we will then use a robust design (a randomised controlled trial) to assess whether stopping double-checking of medicines reduces costs without increasing patient harm. We will also explore how the intervention works in practice and how local factors (e.g. clinical setting, leadership) influence what happens. We will work with our network of stakeholders, including lay leaders, throughout this programme and share findings through reports, publications, conferences and more creative methods.