Identifying where second-person medication checking has the greatest impact could improve patient safety and make better use of NHS staff time. Identifying where second-person medication checking has the greatest impact could improve patient safety and make better use of NHS staff time.

Research lead:

Prof Bryony Dean Franklin

Quick facts:

  • Each year, there are 47 million medication errors in English hospitals, of which 37 million occur when the patient is being given the medication
  • To reduce the risk of errors, it is often recommended that a second person does a double-check – but there is not enough evidence to prove that this is effective
  • Double checking medicines on hospital wards costs NHS England an estimated £733mn each year in staff time

Every year, there are 37 million medication administration errors in English hospitals. While many do not cause serious harm, others can lead to longer hospital stays or even death. To reduce this risk, many NHS hospitals use a system called “second-person checking”. One healthcare professional prepares the medicine, then another double checks it before the medicine is given to the patient. However, there is limited evidence that this approach consistently prevents errors, and it costs the NHS millions of pounds each year in staff time.

This study, led by Professor Bryony Dean Franklin and funded by the NIHR, is examining how second person checking “works”. The team will observe practice, and interview staff and patients to explore whether and how the system improves safety in a range of clinical areas in four different hospitals.

They will look at how responsibility is shared and whether:

  • checks are mandatory or optional
  • checks are carried out independently or together
  • differences in seniority or experience affect outcomes

Their aim is to identify the key “ingredients” needed for the system to work, as well as when and why it doesn’t. Their findings will inform guidance for healthcare professionals on how and where to use second person checking, and where it adds no value.

This could improve patient safety, reduce NHS workload and costs, and ensure staff time is focused where it makes the greatest difference.