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moving things along I donamp;#39;t need to reintroduce Joanna weamp;#39;ve all heard about it double does double checking reduce medication administration errors interesting question thank you very much George so this presentation is really an opportunity that we took um while we were doing this direct observational study of nurses I think first of all we would like to thank those almost 300 nurses at the hospital who allowed our researchers to follow them around during the wards it was an incredibly generous um of them to allow us to do that so one of the things that it weamp;#39;re able to do which is Magda pointed out is not only look at whether there were errors but look at the procedures that the nurses were undertaking so letamp;#39;s think first of all about double checking and as a policy internationally it is used extensively and the overall assumption is that if you have two people checking at least one of themamp;#39;s probably going to pick up an error if itamp;#39;s