Work

Why double-checking can fail in medication safety: An exploratory eye-tracking analysis of nurses’ visual attention and interpersonal coordination

Year: 2026

Type: article

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.

Source: Human Factors in Healthcare

DOI: 10.1016/j.hfh.2026.100162