Investigators evaluated checklists designed for an “independent
double checking” process in which the second person, without
referring to the first person’s work, decides upon a setting or
dosage, then checks his/her conclusions with those of the first
person. Checklists were evaluated in a simulator to identity
components that were most effective in identifying chemotherapy
The article details what worked and what did not. For example,
general reminders did not help (e.g., “follow the five rights of
medication administration”). Their primary recommendations for
developing a checklist were:
Determine the errors with high risk or high probability that
could reach the bedside, using a technique such as failure modes
and effects analysis.
Develop specific checklist instructions for each predictable
error. Include details of what information to check (e.g., dose
in mg) and from what sources (physician’s order and drug label).
Keep the list short by omitting items with lower risk and lower
If the possibility of an error is abstract or general (e.g.,
error in physician’s dosage choice), but the error itself has a
high severity or probability, break the error down into smaller,
more specific steps that can be added to the instructions (e.g.,
check dosage on medication order against hospital drug formulary
of appropriate adult doses).
Determine the workflow of the first and second nurses by
observing them working in their natural environment using a
technique such as contextual inquiry.
To encourage efficiency and adoption, assemble the itemized
instructions into a checklist that corresponds with their
workflow, and use language and terms that match their existing
tools such as the infusion pump screen prompts.
To test and improve the usability of the checklist, recruit a
small sample of end users (three to six people) to use the
checklist while you observe. If they become confused, use the
checklist in a way that is not anticipated, or readily miss
errors, refine the design of the form to be more intuitive, and
repeat the testing process.
For each potential error not included on the checklist,
develop alternate strategies to prevent it from reaching the
bedside. Continue to develop additional strategies for
eliminating all possible errors, even those that can be
identified with the checklist, since no human checking process is
1. White RE, Trbovich PL, Easty AC, et al. Checking it twice: an
evaluation of checklists for detecting medication errors at the
bedside using a chemotherapy model. Quality & safety in health