It Takes Two

Published 27 October 2017. Last updated 10 November 2017.

It Takes Two was designed to educate nursing staff and managers on NSW Health and local policies regarding medication handling, with the aim of improving patient safety in the emergency department (ED).


To increase compliance of two nurses double-checking intravenous (IV) medications and fluids by the patient’s bedside in the ED, by 60 per cent by August 2017.


  • Reduces clinical incidents related to IV medications and fluids in the ED.
  • Improves patient safety and health outcomes.
  • Increases compliance with NSW Health and local health policies.
  • Improves staff awareness of best practice medication handling.


In 2017, the Medication Safety Working Party at St George Hospital identified that IV medication and fluid errors were the second highest category of incidents reported within the ED. Anecdotal evidence provided by clinical nurse consultants and education teams also suggested this was an area of concern.

Checking medications before they are administered by nurses is a basic preventative action, with some research showing that medication errors are reduced when double-checking occurs1. Double-checking refers to a process where one nurse prepares the medication and another double checks that it is correct before it is administered.

While there is a policy directive from NSW Health mandating the use of double-checking in public health facilities, in practice it is often seen as a burden for nursing staff and not consistently implemented. Prior to the project, a review of Incident Information Management System data, a baseline audit and anecdotal evidence from focus groups demonstrated poor compliance with two nurses completing all mandatory checks at the bedside. This had a direct impact on patient outcomes, reflected in high severity incident scores.


  • All ED nursing staff were emailed a copy of the NSW Health policy relating to medication handling2, as well as the St George/Sutherland Hospitals and Health Services (SGSHHS) clinical business rule on IV medication therapy3, highlighting relevant sections on IV medication administration requirements.
  • The policy directive and clinical business rule were included in the orientation package provided to new nursing staff, who were asked to read and sign a statement to acknowledge their role and responsibilities in this area.
  • A series of one-hour PowerPoint education sessions were provided to all ED nursing staff and managers, outlining the project goals, baseline compliance data and solutions to be implemented. These sessions engaged staff, raised the profile of the project and gave staff an opportunity to contribute and provide feedback on solutions implemented.
  • Laminated visual prompts highlighting the policy on double-checking and encouraging staff to ‘find a check-mate’ were posted in all medication preparation areas and rooms in the ED.

Project status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.


August 2016 – August 2017

Implementation sites

Emergency Department, St George Hospital, South Eastern Sydney Local Health District



  • 75 per cent of ED nursing staff and managers attended in-service education by August 2017.
  • Anecdotal reports showed that staff used the ‘It Takes Two’ catchphrase when asking for someone to check IV medications.
  • Double-checking IV medication and fluid orders increased by 5 per cent, from 75 per cent to 80 per cent compliance.
  • Compliance with the same two nurses double-checking IV medication, fluid, patient identification and allergies at the bedside increased by 35 per cent, from 30 per cent to 65 per cent.
  • Compliance with the same two nurses double-checking the administration and/or rate on pump at the patient’s bedside increased by 40 per cent, from 20 per cent to 60 per cent.
  • Compliance with IV medication and fluid orders co-signed by two nurses after administration increased by 40 per cent, from 45 per cent to 85 per cent.
  • An audit measuring the impact of the laminated visual prompt is underway.

Lessons learnt

Quality improvement projects can be challenging to coordinate, manage and implement within a dynamic environment like the ED. However, the involvement of key stakeholders when brainstorming solutions had a positive impact on outcomes.


  1. Lapkin S, Levett-Jones T, Chenoweth L et al. The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews.  Journal of Nursing Management 2016;24(7):845-858.
  2. NSW Ministry of Health. Medication Handling in NSW Public Health Facilities. Policy Directive PD2013_043. North Sydney: NSW Health; 2013.
  3. St George/Sutherland Hospitals and Health Services (SGSHHS). Medications – Intravenous Medications Therapy and Additives. Clinical Business Rule CLIN115. Kogarah: SGSHHS; 2014.

Further reading

This project adopted as it's theme the 1965 song It Takes Two, co-written by William Stevenson and Sylvia Moy and performed by Marvin Gaye and Kim Weston.


Jennifer Ings
Acting Clinical Nurse Educator - Emergency
St George Hospital
South Eastern Sydney Local Health District
Phone: 02 9113 1680

Lisa Johnson
Acting Nurse Educator - Emergency
St George Hospital
South Eastern Sydney Local Health District
Phone: 02 9113 4666

Stephanie McPherson
Clinical Nurse Specialist - Emergency
St George Hospital
South Eastern Sydney Local Health District
Phone: 02 9113 1680


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