SASI-MEDS - Exploring current practice for medication checking
Research type
Research Study
Full title
SASI-MEDS - Exploring current practice for double checking and single checking of medicines: A Qualitative study.
IRAS ID
357782
Contact name
Rebecca Lawton
Contact email
Sponsor organisation
Bradford Teaching Hospitals NHS Foundation Trust
Duration of Study in the UK
5 years, 0 months, 1 days
Research summary
Every day in NHS hospitals there are approximately 130,000 medication errors. Over three quarters of these errors happen while giving medicines to patients (medication administration errors). These errors, such as giving the wrong dose or medicines to the wrong patients, occur frequently and can harm patients. In very rare cases, errors cause severe harm or death. Strategies to reduce errors include double-checking. Here, two registered nurses check that the medicine is the right one for the patient and that the dose is correct, before giving the medicine.
At the moment, there is no convincing evidence that double-checking reduces medication administration errors.
Research has also found that double-checking can harm patients because it leads to delays in patients getting critical medicines. Also, because nurses spend so much time on this activity (6.4 minutes per check), double-checking has been estimated to cost the NHS between £412 million and £1.28 billion per year. 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. So, nurses’ time could be better spent doing other tasks that improve patient outcomes, such as other safety-focused work. It is unsurprising then that in 2022 NHS England said that knowing whether 'double-checking medications reduces errors' was a national research priority.The overall aim of this research study is to explore current practice around the double-checking of medicine administration and to learn from the successful and unsuccessful attempts that NHS trusts have made to reduce double-checking practice.
Our aim is to explore the barriers and enablers to reducing double-checking medicines. We will use a range of methods, including observation and interviews to understand current practice of double-checking medicines in English hospitals.
REC name
South Central - Oxford A Research Ethics Committee
REC reference
25/SC/0215
Date of REC Opinion
8 Jul 2025
REC opinion
Further Information Favourable Opinion