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June 2010, Volume 40 Number 6 , p 12 - 12


  • Michael R. Cohen ScD, MS, RPH


Double-checking critical work is a recommended risk management procedure, but some healthcare providers may feel that the small number of problems that are missed initially doesn't justify the extra time spent double-checking when clinicians are already struggling with staff shortages and other time resource issues. But because most facilities have experienced errors that reached patients despite double-checks, the value of double-checks is in the spotlight again.Properly conducted double-checks identify errors at a higher rate than people realize, and only about 5% of errors are missed on a double-check. One reason is that people typically are better at finding others' mistakes than their own. Confirmation bias limits your ability to see your own errors—you may not realize you've selected the wrong drug because you can see only what your mind thinks you should be seeing. Putting a fresh pair of eyes on something improves checking accuracy.Double-checks work best when

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