Oliver usually worked the pm shift at the prison but was helping out in a staffing pinch over the summer vacation period. He regularly does the evening medication round so volunteering to do morning medications didn’t seem like a bad deal. Everyone is hurried as there was a man-down called for one of the housing units and the patient is being settled in the infirmary. Although there is a standing policy to have anticoagulant doses double-checked by another nurse, he decides to do the simple calculation himself. Without a calculator handy, he does the math in his head and documents that he had administered 7.5 mg of warfarin to Inmate Strump. In reality, he just gave double the prescribed dose as the tablets were 10mg rather than 5mg, as he thought he was using.

The need to calculate a dose based on available forms or strengths of medication can lead to mathematical error. If at all possible, medication formulation needs to be in the strength necessary for the prescribed dose. When medication is being titrated, like the warfarin above, the changes come too fast for this pharmacy oversight. Nurses often need to calculate the dose and convert to available pill strength from stock.

Even simple math calculations can be challenging in a noisy housing unit with many distractions. While limiting the variety of strengths of various medications in stock may reduce the error of selecting the wrong strength of medication for a particular patient; relying on only one stock strength of medication increases the need to split scored medications and to make on-the-spot mental mathematical calculations. Both increase error risk.

Calculation Double-Checks

Complicated calculations or high-risk medication calculations call for an added level of safety. We cannot always see our own mistakes and a set of independent ‘fresh eyes’ are needed in high risk situations. However, double-checking medication doses is time consuming and other nurses are not always available to stop and help. So selective use of an independent double-check process before administering certain medications is recommended by the Institute of Safe Medication Practices

What to Double Check

Health care safety organizations such as the Institute for Safe Medication Practices (ISMP) publish lists of high risk medications based on ongoing analyses of life-threatening medication administration errors. Some medications make the list based on look-alike/sound-alike qualities and the dangerous patient outcome if the wrong medication is administered. An example of this might be confusing MetFORMin (Glucophage) with MetroNIDAZOLE (Flagyl). Most, however, are high risk related to the danger of providing an incorrect overdose. This is of particular concern for pediatric, oncology, and geriatric patient populations as they have less reserves to process an inappropriate dose and may have complex medication regimens prone to error. Categories of high risk medications in acute care settings according to the Joint Commission and ISMP include anticoagulants, opiates, insulins, chemotherapeutics, and sedatives.

What high-risk medications should require a double check in the correctional setting? Certainly, if chemotherapeutics are provided, particularly as an IV additive, they should be independently checked by another nurse before administration. But, how about other, more common, categories such as anticoagulants and insulins? Both medications can have a seriously adverse patient outcome if an incorrect dose is administered. Insulin, in particular, has many strengths and formulations; making administration errors even more likely.

Too Much Trouble

A major reason many settings do not enforce a double-check policy (even when it is on the books) is because it is time consuming and often incorrectly performed. Here are some recommendations from ISMP on how to perform an effective medication double-check process:

• Only use a double check process for the highest risk medications otherwise the process is likely to fall to the wayside due to time and availability issues.
• Make sure the double check is totally independent. The second nurse should check the order, calculate the dose, and compare to the first calculation without additional information or interpretation. This reduces the chance that the double-check follows the same error path as the first calculation.
• Don’t let the double-check process become superficial. Make the review an active engagement in the process. Do not assume it is correct because the practitioner is a trusted and high-level colleague. Mistakes happen to everyone!
• Establish a standardized process (mental or written checklist) for calculation double-checks. Consider these items in the list.
  • Is this the medication ordered?
  • Is this the dose ordered?
  • How is the dose calculated? Redo the calculation independent of the original calculation.
  • Is this the correct patient?
  • Is this the correct time for administration?
  • Is this the correct route for administration?

Although standardized dose calculation double-checks are an important part of reducing medication administration error, they cannot overcome a faulty system and should not be the only safety mechanism in place.

Do you use medication calculation double checks in your setting? Share your experiences in the comments section of this post.

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