{
  "abstract": "Background: Medication administration errors are a global patient safety challenge. While verification protocols such as double-checking are widely utilized for preventing these errors, empirical evidence of their effectiveness remains inconclusive. Traditional observational methods often fail to capture the underlying cognitive and perceptual processes of “work-as-done.” Purpose: We investigated differences in nurses’ visual attention and physical actions during single- and dependent double-checking procedures for injectable medications. Using head-mounted eye-tracking devices, the research sought to capture perceptual and attentional components of “work-as-done” that are often invisible to traditional observational methods. Method: In this exploratory simulation study, 16 nurses from two hospitals performed simulated medication-checking while wearing Microsoft HoloLens 2 head-mounted devices. Their gaze data were recorded and analyzed for six participants alongside first-person video recordings of their physical actions for all 16 participants. Visual attention was assessed via dwell counts and dwell times on the prescription sheet, medication label, and medication. Results: Medications attracted the least visual attention during checking procedures. Behavioral analysis showed that checkers often finished their verification or looked away while their partner was still reading, and some nurses seemingly failed to look at the medication even while holding it. Additionally, larger medications appeared to attract a greater share of visual attention under dependent double-checking. Conclusions: This study revealed a gap between “work-as-imagined” and “work-as-done.” Dependent double-checking may inadvertently reduce vigilance due to interpersonal coordination issues.",
  "abstract_shown": true,
  "affiliations": [
    "Department of Patient Safety, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Corresponding author at: Department of Patient Safety, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.",
    "Department of Patient Safety, Graduate School of Medicine, Kyoto University, Kyoto, Japan",
    "Department of Pharmacy, Osaka Red Cross Hospital, Osaka, Japan",
    "Center for Medical Education and Internationalization, Kyoto University, Kyoto, Japan",
    "Integrated Clinical Education Center, Clinical Simulation Center, Kyoto University Hospital, Kyoto, Japan",
    "Department of Gastroenterological Surgery, Graduate School of Medicine, The University of Osaka, Osaka, Japan",
    "Division of Public Health, Department of Social Medicine, Graduate School of Medicine, The University of Osaka, Osaka, Japan; Artificial Intelligence Center for Medical Research and Application, The University of Osaka Hospital, Osaka, Japan",
    "Division of Nursing, The University of Osaka Hospital, Osaka, Japan"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 12,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Altanshagai Ganbileg"
    },
    {
      "affs": [
        1
      ],
      "name": "Mariko Morishita"
    },
    {
      "affs": [
        1
      ],
      "name": "Megumi Iida"
    },
    {
      "affs": [
        2
      ],
      "name": "Takashi Yamamoto"
    },
    {
      "affs": [
        3
      ],
      "name": "Akira Yamamoto"
    },
    {
      "affs": [
        1
      ],
      "name": "Sawako Hiroi"
    },
    {
      "affs": [
        1
      ],
      "name": "Karin Kato"
    },
    {
      "affs": [
        4
      ],
      "name": "Maki Someya"
    },
    {
      "affs": [
        5
      ],
      "name": "Norikatsu Miyoshi"
    },
    {
      "affs": [
        6
      ],
      "name": "Ryo Kawasaki"
    },
    {
      "affs": [
        7
      ],
      "name": "Ayako Fujii"
    },
    {
      "affs": [
        1
      ],
      "name": "Yumi Matsumura"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/2z7abhyktj5fd.bib",
  "cited_by": 0,
  "doi": "10.1016/j.hfh.2026.100162",
  "fulltext_url": "http://www.sciencedirect.com/science/article/pii/S2772501426000400",
  "id": "2z7abhyktj5fd",
  "issns": [
    "2772-5014"
  ],
  "landing_url": "https://doi.org/10.1016/j.hfh.2026.100162",
  "language": "en",
  "licence": "CC-BY",
  "licence_label": "CC BY",
  "licence_source": "journal",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "lcc",
      "R"
    ],
    [
      "openalex",
      "3604|Patient Safety and Medication Errors"
    ]
  ],
  "openalex": "W7222605097",
  "pdf_url": "https://www.sciencedirect.com/science/article/pii/S2772501426000400/pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-30",
  "publisher": "Elsevier",
  "ris": "https://research.draconitic.com/paper/2z7abhyktj5fd.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T13:44:31Z",
      "native_id": "6871d4129cbe468ba9d0692d39e244d1",
      "source": "doaj",
      "url": "https://doi.org/10.1016/j.hfh.2026.100162"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "lcc:R",
      "subfield": "general"
    }
  ],
  "title": "Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination",
  "title_text": "Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T13:44:31Z",
  "url": "https://research.draconitic.com/paper/2z7abhyktj5fd",
  "venue": "Human Factors in Healthcare",
  "versions": []
}