PURPOSE To establish a standardized process for the activity of an independent double check for medication administration. POLICY STATEMENTS Health Care Providers will complete the independent double check process for ALL high alert medications as listed in policy PTN.01.010. Two health care providers shall independently verify: The most current prescriber order or medication administration record The patient s relevant lab values and/or diagnostic results Medication dosage calculations The following medication rights: o RIGHT patient/client (two unique identifiers) o RIGHT drug o RIGHT dose o RIGHT time o RIGHT route o RIGHT indication o RIGHT documentation Intravenous or epidural medications also include: o RIGHT diluent o RIGHT concentration o RIGHT rate of administration o RIGHT expiry dating Pump programming for intravenous or epidural medication SITE APPLICABILITY The policy for the process of completing an independent double check is applicable in all clinical areas where high alert medications are administered to patients at BCCH and BCWH. This policy excludes medications administered by anesthesiologists. PRACTICE LEVEL/COMPETENCIES The process of completing an independent double check is a foundational competency for all Health Care Providers providing care and services to patients at BCCH and BCWH. Health care providers: Registered Nurse (RN), Licensed Practical Nurse (LPN), Nurse Practitioner (NP), Student Nurse (SN), Registered Respiratory Therapist (RRT), Student Respiratory Therapist (SRT), Registered Psychiatric Nurse (RPN), pharmacists and physicians compound, dispense or administer medications that are within their scope of practice as defined by their respective College and approved by the Health Authority/Agency. DEFINITIONS High Alert Medication is any medication that is deemed to possess higher risk of causing significant harm in a patient even if used as intended. Risk is increased if the agent is used in error (of any type), dosed inappropriately, requires stringent physiological monitoring for patient safety and/or has a narrow dosing or blood/response window of use. Page 1 of 5
Independent Double Check (or abbreviated as IDC ) is a process in which a second practitioner, alone, conducts a verification of work or a decision of an initial practitioner. Such verifications can be in the presence or absence of the first practitioner but, in either case, the most critical aspect is to maximize the independence (unbiased assessment) of the second check, by ensuring that the first practitioner does not communicate what he/she expects the second practitioner to conclude is correct. Medication Order is an order for any medication, nutritional agent or compound defined by the institutional policy as requiring an order from a prescriber. Health Care Provider (HCP) For the purpose of this policy, health care provider refers to an individual with required medication administration competencies (i.e. RN, RPN, LPN, NP, RRT, physician and pharmacist). PROCEDURES Procedure Rationale Health Care Provider 1 and 2 independently verify: Current prescriber order Patient s relevant lab values and/or diagnostic results Step 1 Health Care Provider 1 independently: Verifies medication(s) using the medication rights Completes the medication calculations Draws up the medication(s) dose Reduces risk of medication administration errors. To determine correct dose to administer. DO NOT Communicate medication calculation(s) results to Health Care Provider 2 Mix the medications at this step Step 2 Health Care Provider 2 independently: Verifies medication(s) using the medication rights Completes the medication calculation(s) Administering some medications requires added safeguards to ensure the right drug and dose is given to the right patient, at the right time, for the right reason. To determine correct dose to administer. Page 2 of 5
Step 3 Health Care Provider 1 and Health Care Provider 2 compare medication dose and calculation results If there are any discrepancies: repeat the independent double check process (steps 1-3) If discrepancies still exist: a third healthcare provider must perform the independent double check process (steps1-3) If discrepancies remain: after a third healthcare provider completes the independent double check process, Health Care Provider 1 shall clarify the medication order(s) with the authorized prescriber. If more than one medication is to be prepared in a single syringe, Health Care Provider 2 must observe and verify the correct dose of each medication. When the independent double check verifies the medication preparation to be correct, Health Care Provider 1 prepares to administer the medication. Note: Health Care Provider 1 administers only medications they themselves or a pharmacist have prepared, except in an emergency (e.g. Code Blue). Is the medication administered via infusion pump? Yes - proceed to step 4 No - administer medication Infusion Pump Administration High Alert Medication Step 4 Health Care Provider 1: Verifies patient identity Mixes the medication and completes the medication preparation Prepares medication for infusion on pump (hang bag/syringe) Program the infusion pump in accordance to the most current medication order and relevant medication administration policies/guidelines/protocols Failure to correctly identify patients prior to procedures may result in errors. For smart infusion pumps (i.e. Alaris) administer the medication as per the infusion pump library, when available. Automated Identification (bar code) scan of drug and drug concentration (container) is acceptable as an IDC, however the infusion rate (or duration) Page 3 of 5
Perform site-to-source check must have an independent double check (IDC). Health Care Provider 2: Verifies patient identity Compares the pump programming to the most current medication order and relevant medication administration policies/guidelines/protocols If there are any discrepancies: Note: When medications are prepared in advance Healthcare Provider 2 in step 4 may be a different individual than Healthcare Provider 2 in steps 1-3. Automated Identification (bar code) scan of drug and drug concentration (container) is acceptable as an IDC, however the infusion rate (or duration) must have an independent double-check (IDC). Reduces risk of medication administration errors. repeat the independent double check process (step 4) If discrepancies still exist: a third healthcare provider must perform the independent double check process (step 4) If discrepancies remain: after a third healthcare provider completes the independent double check process, Health Care Provider 1 shall clarify the medication order(s) with the authorized prescriber. When the independent double check verifies the medication preparation and infusion pump settings to be correct, Health Care Provider 1 proceeds with the medication administration and initiates the infusion. *Note - An independent double check by a second HCP is required any time the following changes are made: Initiation of an infusion Rate/dose change Restarting an infusion after interruption At shift change and/or permanent handover of care Page 4 of 5
DOCUMENTATION Document the independent double check on the appropriate patient health record i.e. medication administration record (MAR). Documentation includes: Signature or initials of participating health care professionals Date and time the checks were performed Note: Documentation of medication administration is done by the person administering the medications except in emergency situations, such as code blue when a nurse, designated as recorder, documents medications given by others. Those who gave the medications are required to countersign the resuscitation record as soon as possible following the event. REFERENCES 1. Alberta Health Services Authority. (2012). Policy: CO-2.034 Independent Double Check High Alert Medication Administration. 1-5. 2. Children s Hospital of Eastern Ontario (CHEO). (2014). Policy: Independent Double Check for High Alert Medications. 1-6. 3. Cohen, M. (2010). Medication errors: Independent double check. Nursing, June. Retrieved September 2015 from www.nursing,com. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17915527 4. Conroy, S., Davar, Z., & Jones, S. (2012). Use of checking systems in medicines administration with children and young people. Nursing Children and Young People, 24(3). 20-24 5. Federico, F. (2007). Preventing harm from high-alert medications. The Joint Commission Journal on Quality and Patient Safety, 33, (9), 537 542. 6. Hicks, R. W., Becker, S. C. & Cousins, D. D. (2006). Harmful medication errors in children: A 5 Year analysis of data from the USP s MEDMARK Program. Journal of Pediatric Nursing, 21, (4), 290 298. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16843213 7. Kennedy, D. (1996). Medication safety checks in pediatric acute care. Journal of Intravenous Nursing, 19(6). 295-302. 8. Saskatoon Health Region. (2013). Policy Number: 7311-60-020: High Alert Medications - Identification, Double check, and Labeling. 1-11. Retrieved from https://www.saskatoonhealthregion.ca/about/rwpolicies/7311-60-020.pdf 9. Van Veen, B. (2012). Implementation of the independent double check process in an outpatient oncology unit. Canadian Oncology Nursing Journal ROSIO Spring/Printemps 2012. 150-151. Page 5 of 5