Identifying barriers and enablers for a robust independent second check of medication in adult intensive care

Background: Independent second-checking of medication is part of everyday practice across many parts of the NHS. A robust, independent second check is built into medication administration protocols to reduce the risk of drug errors affecting patients.

Aim: This work aims to determine the barriers and facilitators regarding a robust independent second check of medication before administration to patients within adult critical care.

Method: Nurses in adult critical care were invited to participate in focus groups. They were asked to discuss factors that they felt enabled or prevented a robust second check of medication. Thematic analysis was undertaken by three critical care pharmacists.

Findings: The major themes identified as barriers to an independent second check were: geography of the critical care unit; IT; routine; complex process; and personnel.

Conclusion: There are complex barriers to undertaking a robust second check and addressing some of these could improve patient safety.