Which Features of Medication Double-Check Procedures are Considered Desirable and Implemented in Practice? A Cross-Sectional Web-Based Vignette Study among Nurses in Japan
- 1National Institute of Advanced Industrial Science and Technology
Abstract
ObjectiveNurses specific medication-administration double-check procedures vary widely; while independent double-checks (IDCs) are considered effective and recommended, they are implemented insufficiently in practice. This study aimed to classify these procedures by their component features and determine which features nurses consider desirable and perceive as implemented in clinical practice.
DesignCross-sectional web-based vignette study
Setting, participants, and methodsNurses working in Japanese hospitals or clinics participated in this study, for which we created 84 scenarios by combining checking procedures features, including independence between checkers, across the calculation, preparation, and administration stages. For each scenario, participants self-reported the desirability of the procedure and its perceived implementation frequency in their clinical setting. Linear mixed-effects models assessed associations between checking-procedure features and each rating, and McNemars test assessed discrepancies between desirability and implementation frequency for IDC.
Primary outcomeAssociations between double-check procedures features and their desirability and implementation frequency, and the alignment between desirability and implementation frequency for IDC
ResultsOf 534 respondents, 265 were analyzed after prespecified attention-check exclusions. Independent checking was positively associated with desirability (b=0.304, 95% CI [0.255, 0.353], p<0.001), perceived implementation frequency for high-risk medications (b=0.140, 95% CI [0.080, 0.200], p<0.001), and non-high-risk medications (b=0.083, 95% CI [0.022, 0.143], p=0.008). Only 22.5% of nurses perceived IDC as the most frequently implemented procedure during the calculation stage. Moreover, 23.4% rated IDC as the most desirable, but did not report it as the most frequently implemented, whereas 8.1% showed the reverse pattern (OR=2.89, 95% CI [1.69, 4.94], p<0.001).
ConclusionsAlthough independence, a key feature of IDC, was reflected in nurses desirability ratings and perceived implementation frequency, IDC was not the most frequently implemented checking procedure, relative to others. Implementing IDC may require not only promoting understanding of its significance but also establishing work protocols and organizational environments that enable independent checking.
Related
- Antibiotic Prophylaxis During Invasive Dental Procedures in Patients With Prosthetic Heart Valves ― Cross-Sectional Analysis of Japanese Claims Data ―
- Medication Adherence in Patients With Glaucoma and Determinants of Treatment Adherence: A Cross-Sectional Study
- Development of a nomogram for identifying prevalent medication discrepancy in maintenance hemodialysis patients: a multicenter cross-sectional study
- Antidepressant medication use and objectively measured physical activity and sedentary behaviors in adults: A cross-sectional analysis of a nationally representative sample of Canadian adults
- Medication and Antibiotic Use Among Children Reported by an Online Convenience Sample of Parents in Serbia: A Cross-Sectional Survey
BibTeX
@misc{morimoto2026which,
title = {{Which Features of Medication Double-Check Procedures are Considered Desirable and Implemented in Practice? A Cross-Sectional Web-Based Vignette Study among Nurses in Japan}},
author = {R. Morimoto and T. Sakura and K. Sato and K. Ueda and R. Kagawa},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.04.26364685},
url = {https://www.medrxiv.org/content/10.64898/2026.10.04.26364685v1},
note = {CC BY-NC},
}
RIS
TY - UNPB
TI - Which Features of Medication Double-Check Procedures are Considered Desirable and Implemented in Practice? A Cross-Sectional Web-Based Vignette Study among Nurses in Japan
AU - R. Morimoto
AU - T. Sakura
AU - K. Sato
AU - K. Ueda
AU - R. Kagawa
PY - 2026
DA - 2026/10/04
PB - medRxiv
DO - 10.64898/2026.10.04.26364685
UR - https://www.medrxiv.org/content/10.64898/2026.10.04.26364685v1
AB - ObjectiveNurses specific medication-administration double-check procedures vary widely; while independent double-checks (IDCs) are considered effective and recommended, they are implemented insufficiently in practice. This study aimed to classify these procedures by their component features and determine which features nurses consider desirable and perceive as implemented in clinical practice. DesignCross-sectional web-based vignette study Setting, participants, and methodsNurses working in Japanese hospitals or clinics participated in this study, for which we created 84 scenarios by combining checking procedures features, including independence between checkers, across the calculation, preparation, and administration stages. For each scenario, participants self-reported the desirability of the procedure and its perceived implementation frequency in their clinical setting. Linear mixed-effects models assessed associations between checking-procedure features and each rating, and McNemars test assessed discrepancies between desirability and implementation frequency for IDC. Primary outcomeAssociations between double-check procedures features and their desirability and implementation frequency, and the alignment between desirability and implementation frequency for IDC ResultsOf 534 respondents, 265 were analyzed after prespecified attention-check exclusions. Independent checking was positively associated with desirability (b=0.304, 95% CI [0.255, 0.353], p<0.001), perceived implementation frequency for high-risk medications (b=0.140, 95% CI [0.080, 0.200], p<0.001), and non-high-risk medications (b=0.083, 95% CI [0.022, 0.143], p=0.008). Only 22.5% of nurses perceived IDC as the most frequently implemented procedure during the calculation stage. Moreover, 23.4% rated IDC as the most desirable, but did not report it as the most frequently implemented, whereas 8.1% showed the reverse pattern (OR=2.89, 95% CI [1.69, 4.94], p<0.001). ConclusionsAlthough independence, a key feature of IDC, was reflected in nurses desirability ratings and perceived implementation frequency, IDC was not the most frequently implemented checking procedure, relative to others. Implementing IDC may require not only promoting understanding of its significance but also establishing work protocols and organizational environments that enable independent checking.
ER -