Building On the Five Rights
How the foundation for safe medication delivery gets stronger
By Annette L. Perschke, RN, MSN, CRRN
Monday August 25, 2008
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Every nurse learns the five medication rights – the right patient, the right medication, the right dose, the right route, and the right time – and expects following this process will prevent errors. But the five rights do not guarantee safety. Medication administration takes place within a framework of systems that can be flawed and contribute to errors.
Technology, such as computerized prescriber order entry (CPOE) and bar code medication administration, serves as a helpful tool, but nurses cannot abandon critical thinking. They must identify and address system weaknesses and human factors that adversely affect medication safety.
Nurses need to think defensively all of the time by asking "what if" and "why" questions. "What will happen if I don't do something or if I do something wrong? Why am I hanging this IV or giving this antibiotic?"
It is defensive thinking that could improve patient care and safety.
Right No.1: The right patient
The right patient is the one who is prescribed the medication and whose ID band reflects the same identifying information as the medication administration record.
Hand-written systems are prone to errors, which can result in the medication order being placed on the wrong patient's medication administration record. The mistake can occur when the prescriber writes the order or when the nurse transcribes it. Asking a second nurse to check the transcription helps, but errors can be missed.
This is where technology helps. CPOE provides a higher level of certainty for identifying the right patient and transfers data electronically, eliminating the error-prone paper transcription process. Bar code scanning of the ID band and the medication will alert a nurse about to make a wrong-patient mistake.
Right No.2: The right medication
Nurses often wrongly assume the original medication order is correct. Blindly following orders leads to trouble. Nurses must think more critically and assess why the patient is getting the medication. If the order doesn't conform with the patient's condition, maybe he or she shouldn't be receiving it. Question the prescriber.
Information and communication aid in ensuring right medications. Actively participating in daily patient rounds increases nurses' knowledge about plans of care and reasons why agents are ordered.
Also helpful is access to evidence-based practice tools, such as metasearch engines, databases, and computer programs that allow searching for critically appraised topics or clinical trials. PDA software programs offer a handy reference for information about drugs, interactions, and calculations.
Right No.3: The right dose
A nurse's knowledge and understanding of the right dose is dependent on many factors, including educational background, years of practice, and level of experience. But with so much to remember, it's easy to forget.
Standardized order sheets aid everyone involved in patient care, from the prescriber to the nurse. The sheets are specific for a certain diagnosis and list medications ordered at predetermined doses within an accepted range. If you know you can give a certain drug only in strength A or B, it limits the options and the chance for a mistake. If an order falls outside those two choices, it should serve as a red flag. Nurses like the sheets because they do not leave orders open to interpretation. There are no gray areas.
Smart infusion pumps also enhance a nurse's ability to ensure correct dosing. The pumps allow hospitals to enter various drug protocols into a drug library with predefined limits. If a nurse attempts to program outside that parameter, the pump halts or emits an alarm.
Right No.4: The right route
The right route is a critical outcome of safe medication administration. Extensive literature exists documenting medications delivered by the wrong route. These errors often cause significant harm or even death. Relying solely on human knowledge and memory to identify the correct route is unsafe, unreliable, and unpredictable.
A wrong-route mistake often begins with the prescriber omitting or not clearly specifying the route. The nurse then assumes the intent and may guess wrong. The nurse should clarify the order and document the change to prevent the issue from coming up again.
CPOE systems assist to ensure the correct route. The software prevents submission of the order until the prescriber indicates a route. Also, the systems can be programmed to display only the proper routes associated with a particular medication. For instance, if a prescriber were ordering acetaminophen, displayed route choices would not include IV.
Right No.5: The right time
Knowledge of the last dose given, home medication schedules, therapeutic drug levels, and other laboratory information is crucial to administering medications at the right time. Check when the drug was actually given. Never assume the patient received it as scheduled. Surgery, procedures, and diagnostic workups can delay giving a medication. If the nurse does not verify, he or she could administer the next dose too early in relation to the previous dose. If the morning dose, for example, has been delayed, the nurse should check with the prescriber to clarify when the afternoon dose should be administered.
Annette L. Perschke, RN, MSN, CRRN, works at The Johns Hopkins Hospital, Baltimore.
To comment, e-mail editorDC@nursingspectrum.com.
