Second person checking of medication dispensing, preparation and administration in hospitals - what works for whom, in what contexts, and why? The CHECKMED realist evaluation study
Every year, an estimated 47 million medication errors occur in English hospitals, and 37 million of those happen during the simple act of giving a patient their medicine. To prevent mistakes, many hospitals require a second person to check every drug before it is dispensed or administered—a practice called second person checking (SPC). This costs millions of pounds annually, yet there is almost no evidence that it actually makes patients safer, and it can even introduce new risks. This research will determine when, where, and how SPC works—and when it does not. The team will observe medication rounds, interview staff and patients, and analyse existing data across four hospitals. They will build a detailed theory explaining which contexts and mechanisms make SPC effective or counterproductive. If successful, the findings will give NHS policymakers, hospital managers, and frontline staff clear, evidence-based guidance on when to require a second check and when to abandon it. This could save millions of pounds currently spent on unnecessary checks, free up nursing time for direct patient care, and—most importantly—reduce the 2.8 million medication errors each year that cause moderate or severe harm.
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Research question What works, for whom, under what circumstances, and how, in relation to the impact of second person checking (SPC) of medicines on patient safety in NHS hospitals? Background Each year, an estimated 47M medication errors occur in English hospitals, of which 37M occur during medicine administration. Of these, 2.8M cause moderate/severe patient harm; all can affect patient and staff wellbeing. To reduce the risk, many NHS hospitals require a SPC for the dispensing, preparation and administration of some or all medicines. However, there is wide variation in the medicines and processes for which a SPC is required; few policies say clearly how it should be done. SPC costs NHS hospitals millions of pounds a year, but there is little evidence to support its use, and it can introduce new risks. SPC is therefore complicated and expensive, with little evidence to say if and how it should be used. Policymakers, managers and frontline staff need guidance on how it should best be used to support patient safety. Aim & objectives We aim to explore the impact of SPC on medicines safety in hospitals, in terms of what works, for whom, under what circumstances, and how; and to make recommendations to policymakers, managers and frontline staff for how it should best be used. Objectives are: 1.To create an initial programme theory for how SPC for dispensing and administration of medicines is expected to work 2.To test this initial programme theory through data collection in different hospital settings and with different types of SPC 3.To refine the programme theory to establish what works, for whom, under what circumstances, and how, in relation to SPC and its impact on patient safety 4.To collect data on staff time required for SPC to inform preliminary economic evaluation 5.To make recommendations for practice and policy in relation to how SPC of medicines should (or not) be used Methods We will use a realist evaluation, which seeks to establish what works, for whom, in what situations, and how, in the form of a programme theory structured as Context, Mechanism, and Outcome configurations (CMOcs). The study will have four phases: Phase 1: Creating initial CMOcs to describe how SPC is expected to work, based on past research, policy and PPI/stakeholder workshops. Phase 2: Developing this theory by interviewing key people (healthcare staff, patients, researchers, managers). This will be followed by asking these people to prioritise the CMOcs for testing in phase 3. Phase 3: Testing the CMOcs using mixed methods data collection in different areas of 4 hospitals: (1) observation of medication dispensing and administration, (2) interviews with staff, patients and carers, and (3) analysis of existing data. Phase 4: Developing a final programme theory and practice recommendations, via 3 stakeholder workshops. Timelines for delivery Initial CMOcs will be created by Jul 26 (Phase 1), then refined and prioritised for testing by May 27 (Phase 2). Mixed methods data collection will take place Jul 27 to Feb 28 (Phase 3), followed by stakeholder workshops in May 28 (Phase 3). Dissemination activities will take place Jul to Oct 28. Anticipated impact & dissemination Supported by our steering group, we will use our stakeholder/dissemination matrix to share recommendations with healthcare staff, managers, policy makers and guideline authors, to inform policy and practice around SPC. Our PPI group will help share our work with the wider public.
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