Doble verificación: mal utilizada y no valorada en prácticas de medicación segura – ISMP

High-alert medications are drugs that bear a heightened risk of causing significant harm to patients or residents when they are used in error. A manual independent double check of high-alert medications is a strategy that has been widely promoted in healthcare to help detect potentially harmful errors before they reach patients or residents. 1-3 On the other hand, independent double checks used as a risk-reduction strategy have long been disputed as well as misused in healthcare. Its use has been a source of stress for busy nurses, pharmacists, and prescribers who are short on time. Its impact on safety has been questioned by those who rarely find mistakes during the checking process. Inconsistent use and variability in how the task is carried out renders it less capable of detecting many errors. Its overuse as a risk-reduction strategy for high-alert medications has been challenged given its status as a weak error-reduction strategy, particularly if it is the only safeguard in place. Its frequent misuse as a quick fix for an ailing medication use system has been the bane of managers who have investigated serious errors that have reached residents due to failed double-check processes.

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