Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination
8 affiliations
- 1Department 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.
- 2Department of Patient Safety, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- 3Department of Pharmacy, Osaka Red Cross Hospital, Osaka, Japan
- 4Center for Medical Education and Internationalization, Kyoto University, Kyoto, Japan
- 5Integrated Clinical Education Center, Clinical Simulation Center, Kyoto University Hospital, Kyoto, Japan
- 6Department of Gastroenterological Surgery, Graduate School of Medicine, The University of Osaka, Osaka, Japan
- 7Division 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
- 8Division of Nursing, The University of Osaka Hospital, Osaka, Japan
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.
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BibTeX
@article{ganbileg2026doublechecking,
title = {{Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination}},
author = {Altanshagai Ganbileg and Mariko Morishita and Megumi Iida and Takashi Yamamoto and Akira Yamamoto and Sawako Hiroi and Karin Kato and Maki Someya and Norikatsu Miyoshi and Ryo Kawasaki and Ayako Fujii and Yumi Matsumura},
journal = {Human Factors in Healthcare},
year = {2026},
month = oct,
doi = {10.1016/j.hfh.2026.100162},
url = {https://doi.org/10.1016/j.hfh.2026.100162},
note = {CC BY},
}
RIS
TY - JOUR
TI - Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination
AU - Altanshagai Ganbileg
AU - Mariko Morishita
AU - Megumi Iida
AU - Takashi Yamamoto
AU - Akira Yamamoto
AU - Sawako Hiroi
AU - Karin Kato
AU - Maki Someya
AU - Norikatsu Miyoshi
AU - Ryo Kawasaki
AU - Ayako Fujii
AU - Yumi Matsumura
PY - 2026
DA - 2026/10/30
JO - Human Factors in Healthcare
DO - 10.1016/j.hfh.2026.100162
UR - https://doi.org/10.1016/j.hfh.2026.100162
AB - 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.
SN - 2772-5014
ER -