Outdated, overused and ineffective — time to end mandatory double-checking?

In hospitals, double-checking medications, which requires two nurses to verify a dose before administration, is widely viewed as a critical safety safeguard. But the evidence tells a different story.

Health systems worldwide are under strain, facing workforce shortages, rising patient complexity, and escalating costs. In this environment, making better use of nursing time is not just desirable, it is essential. One opportunity that has received surprisingly little attention is the removal of low-value nursing practices: tasks that consume time without improving patient outcomes.

Around 30% of healthcare activity is estimated to be waste, ineffective or low-value.¹ There is now mounting evidence that double-checking medications is one such low-value practice. Double-checking medications requires two nurses to verify a dose before administration and is one of the most entrenched practices in hospitals around the world. It is widely viewed as a critical safety safeguard. But the evidence tells a different story.

Early accounts of double-checking arose in the 1960s in the United States with the application of engineering principles of redundancy introduced in an attempt to reduce medication administration errors. While intuitively appealing, with the notion that ‘two sets of eyes are better than one’, this assumption was never empirically tested in clinical settings to see whether it actually works at reducing errors.

Over time, the practice spread globally, reinforced by policy and professional norms rather than strong research evidence. Today, it is embedded in many hospital protocols, especially in high-risk areas such as intensive care, oncology and paediatrics.

Does double-checking reduce errors?

Two systematic reviews found little or no reliable evidence that double-checking reduces medication administration errors.^{2, 3} Only recently have robust, large-scale studies confirmed the absence of any safety benefit of double-checking as performed in practice.

Our direct observational study in a paediatric hospital examined over 5100 medication administrations to over 1500 children by 298 different nurses.⁴ Nearly 70% of these administrations required ‘independent’ double-checking according to the hospital’s policy. Independent double-checking specifies that each nurse must asynchronously check each medication step. We found genuinely independent double-checks occurred in just 1% of administrations. For 93% of checks nurses collaborated on sharing information during the checking process. As the Institute for Safe Medication Practices (ISMP) warns, the danger here is of confirmation bias, reducing the effectiveness of the checking process. Our results confirmed this outcome. We found no association between double-checking and reduced error rates or severity.

A 2024 US paediatric ICU study by Leah Konwinski et al. evaluated the removal of mandatory double-checking for high-risk medications.⁵ Monitoring outcomes over 40 months among 4417 children, there were no increases in errors, length of stay, or in-hospital mortality.

Why doesn’t double-checking work?

While intuitively, double-checking would be expected to improve error detection, insights from psychology research explain why this does not occur due to the phenomenon of ‘social loafing’. In essence, social loafing is the tendency for individuals to devote reduced effort to a task when it is shared, with individual accountability diminishing, often resulting in less vigilance and paradoxically fewer errors being identified.

We tested the impact of social loafing on double-checking in a controlled simulation study, where nurses were randomised to either single-check or independently double-check medications.⁶ The results were striking: nurses were 10% less likely to detect deliberately planted errors when working in pairs than when checking alone. This decline in performance reflects social loafing, where individuals subconsciously reduce their effort when working in groups. This effect is not unique to nurses, with multiple studies demonstrating this effect among professional groups from aviation to rescue workers.

Enforcing ‘independence’ in the double-checking process has often been proposed as the solution to improving its effectiveness. Our simulation study was the first to test whether error detection improves with independence.⁶ The results were surprising. Among nurses with less than five years’ clinical experience, enforcing independent double-checking did not improve error detection rates compared to when they single-checked. When checking alone, these less experienced nurses detected significantly more errors than their more experienced colleagues who single-checked.

By contrast, experienced nurses benefited from independent double-checking, showing a significant improvement in their error detection compared to single-checking. However, nurses overwhelmingly reported that performing independent double-checks was not feasible on busy clinical wards and did not reflect routine clinical practice.

Is double-checking harming patients?

There are significant consequences if we keep double-checking. Investing valuable nursing time in this low-value practice takes nurses’ time and attention away from practices that can be life-saving. Each second check takes approximately 6–9 minutes. In one paediatric hospital, with more than 3000 administrations a day, we found ~300 nursing hours per day were consumed by performing second checks, at an annual salary cost of ~$4.5 million.⁴ When extrapolated across Australian hospitals, it’s estimated that around $5 million per day is spent on double-checking with no substantial safety benefit.

Time is also lost simply looking for a second nurse to perform the double-check, often interrupting another clinical task. The result can be delays in care, with patients waiting longer for pain relief or time-critical treatments such as antibiotics. In practice, nurses are constantly balancing competing priorities, administering urgent medications, responding to deteriorating patients and completing multiple tasks simultaneously. Double-checking adds not only workload and stress, but complexity; delays care; and can interrupt other critical work.

This represents a significant opportunity cost. Time spent double-checking could instead be used for high-value care, monitoring patients, communicating with families or early recognition of clinical deterioration —practices shown to deliver improvements in care outcomes.

Why do we keep doing it?

Practices like double-checking persist because they feel safe, align with intuition and are deeply embedded in policy. Reviewing and removing embedded safety practices is difficult and rarely occurs, even as the healthcare context changes dramatically.

When double-checking was first introduced, the nursing workforce looked very different. Nurses were trained through hospital-based, apprenticeship-style programs, with limited formal higher education. Today, the profession has transformed. Nursing is a highly skilled, university-educated workforce, with more than 40% of Australian nurses holding postgraduate qualifications. Expectations of clinical reasoning, accountability and autonomous decision-making have evolved accordingly. At the same time, medication safety has been strengthened with technologies such as electronic medication administration systems, bar-code scanning and automatic dispensing, along with improved packaging and administration delivery devices.

Despite these advances, double-checking remains firmly embedded, and in many instances the number of medications requiring mandatory checks has expanded, further contributing to the ritualisation of the practice. Instead of checking everything twice, nurses should be enabled to apply their clinical expertise and judgement to decide when a second check is warranted.

Double-checking was introduced with good intentions, but the evidence does not support its widespread use. In an era of workforce shortages and increasing demand, continuing practices that consume time without improving outcomes is unsustainable.

Hospitals should consider the need for policy and practice reform to increase single-checking to enhance patient care and outcomes. We have formed a large coalition of paediatric hospitals, policymakers, clinicians and consumers to develop and drive a program to support the de-implementation of mandatory double-checking, allowing nurses to exercise their professional autonomy and expertise.

The goal is to focus on what actually works. By removing low-value practices and empowering nurses to apply their clinical judgment, we can release significant capacity, improve care quality and build a more sustainable health system.

It is time to let go of outdated rituals and allow nurses to use their expertise where it matters most.

^{1. Braithwaite J, Glasziou P, Westbrook J. The three numbers you need to know about healthcare: the 60-30-10 Challenge. BMC Medicine 2020;18(1):102. doi: 10.1186/s12916-020-01563-4}

^{2. Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child 2012;97(9):833–837. doi: 10.1136/archdischild-2011-301093}

^{3. Koyama AK, Maddox C-SS, Li L, et al. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Qual Saf 2020;29:595–603. doi: 10.1136/bmjqs-2019-009552}

^{4. Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. BMJ Qual Saf 2021;30:320–330. doi: 10.1136/bmjqs-2020-011473}

^{5. Konwinski L, Steenland C, Miller K, et al. Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. J Patient Saf 2024;20(3):209–215. doi: 10.1097/PTS.0000000000001205}

^{6. Westbrook JI, McMullan RD, Fitzpatrick E, et al. Is independent double-checking superior to single-checking in medication administration error detection? A randomised controlled simulation trial. BMJ Qual Saf 2026:bmjqs-2025-019743. doi: 10.1136/bmjqs-2025-019743}

*Professor Johanna Westbrook is Director of the Centre for Health Systems and Safety Research at Macquarie University’s Australian Institute of Health Innovation.

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