SaSI-MEDs - exploring current practice for double checking medicines
Research type
Research Study
Full title
SASI-MEDS - Exploring current practice, costs, and consequences of double-checking medicines within NHS Hospital Trusts.
IRAS ID
356129
Contact name
Rebecca Lawton
Contact email
Sponsor organisation
Bradford Teaching Hospitals NHS Foundation Trust
Duration of Study in the UK
1 years, 6 months, 2 days
Research summary
Every day in NHS hospitals there are approximately 130,000 medication errors. Most of these errors happen while giving medicines to patients (medication administration errors). These errors, such as giving the wrong dose to the wrong patient, occur frequently and can harm patients. In rare cases, error can result in severe harm or death. Strategies to reduce errors include double-checking where two registered nurses check that the medicine and dose are correct before giving it to a patient.
There is no convincing evidence that double-checking reduces medication administration errors (MAEs). Research has also found that double-checking can harm patients because it leads to delays in patients getting critical medicines. It also uses a lot of resources. 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 conducted incorrectly, may not work as intended and can, itself, harm patients. As such nurses’ time might be better spent doing other tasks that improve patient outcomes, such as other safety-focused work.This study is part of a NIHR Programme Grant for Applied Health Research. Our aim in this study is to asses the current practice for double-checking medicines alongside its costs and consequences. We want to explore what medicines are double-checked, how double-checks are carried out including how much time they take, what errors are identified through the double-check process, and what errors occur despite double-checks being done. To do this we will observe double-checking of medicines by nurses in at least two services in three NHS Trusts. We will use a range of methods including detailed observations, retrospective patient record review, and extraction of routine data from electronic Prescribing and Medication Administration systems and local risk management systems.
REC name
West Midlands - Black Country Research Ethics Committee
REC reference
25/WM/0136
Date of REC Opinion
21 Jul 2025
REC opinion
Further Information Favourable Opinion