Conduct Independent Double-Checks on the Unit

​Some medications have higher risks than others of causing severe adverse drug events. Double-checks can be a valuable safety mechanism: they help ensure that all data and orders are correct before anyone acts on them. For the double-checks to be effective, at least two people must perform them independently. Checking together runs the risk that both people will make the same error — for example, one person might read the dosage aloud incorrectly and the other might automatically agree.



  • Limit the number of medications calling for double-checks so the requirement does not become burdensome or slow down patient care activities.
  • Use double-checks for some medications only when unusual doses are ordered, which may be when the risk is greatest.
  • Remember that double-checks need two clinical staff members. Patients and relatives should be involved in care, but not in independent double-checks.


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