A COGNITIVE HOOK to help stop medication errors

Here is a simple way to decrease the risk of a medication error occurring due to a hurried or distracted drug check.

When double checking a medication or fluid against the written order with a second nurse, we often say something along the lines of…“would you mind checking this medication order for me?

We then hold up the drug, read it out aloud….and then we check the order off the medication chart (or vice versa).

The second person then (usually nods) and confirms the order (countersigning it in some situations).

This is all well and good. Most of the time.

Although it has been my own experience that when under a high cognitive load, or in conditions of stress and continuous interruption, and then being asked to counter-check a medication ‘on-the-fly’ it is easy to either:

  1. literally see what the person tells you is in front of you. Even if it is incorrect.
  2. not really bring your complete attention to the checking process. Missing any error.

What is this?

Instead of asking someone to check the medication order and then telling them what it is, try asking instead “what is this?”

The simple act of re-framing the question in this way acts as a cognitive hook, forcing the other person to bring their attention to the task, and then to participate in the confirmation process.

It also forces you to listen to the second person articulating the order (and the drug) giving you a second pass at confirming it.

It feels a little forced (and even abrupt) at first….but I think it definitely makes a difference in making both nurses more present to the checking process.

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