US Pharm. 2020;45(6):10-11.
Medical errors and drug-administration mistakes pose significant patient risks. These errors contribute to avoidable patient deaths in the hospital environment. To maintain patient safety and avoid medication errors, it is important that pharmacists, nurses, and other healthcare professionals adhere to the standard for safe medication practices, known as the “five rights” of medication use: the right patient, drug, dose, time, and route.1
Hospital medical mistakes cause as many as 98,000 deaths annually. That exceeds the number of deaths from breast cancer, AIDS, or motor vehicle accidents. Medication errors cause more deaths each year than workplace injuries. The financial cost of these errors compounds the urgent need to address this underappreciated and widespread problem.2
Nurses acquiring medication from a medication dispensing machine should evaluate the medication administration record (MAR) for all five medication-use rights. Adherence to the five rights is not a guarantee against medical errors, however; minor or major mistakes can still occur.1,2
Over the past several years, new technologies to eliminate medication errors have been introduced to the healthcare market, including electronic orders and charting, bar coding that matches patients with medical records, and computerized medication distribution. Although these methods have shown promise, rates of medication errors remain high.1,3
The Five Rights
If a satisfactory system is not set up to help healthcare professionals confirm the five rights, errors are likely to occur.1 A number of factors contribute to the failure of a medical team to confirm the five rights: inadequate staffing patterns, poor lighting, handwritten orders, badly designed medical devices, similar-looking or similar-sounding drugs, trailing zeroes (e.g., 5.0 rather than 5), and decimal points used without leading zeroes (e.g., .5 rather than 0.5), among others. Misinterpretation of medication orders that are ambiguously written can result in a 10-fold dosing error. Other factors are ambiguous drug labels and absence of an effective independent double-check system for high-alert drugs.1,2
For example, nurses administer medication only after confirming a patient’s identity by verifying two unique identifiers assigned upon admission to the facility. Nurses cannot confirm that a specific tablet or vial is the correct drug or that the strength and dosage are correct. However, they are accountable for reading the label, using bar-code technology (if functional), asking for an independent double-check (if required), and questioning orders for medications and dosages that are illegible or seem unsafe.1
These procedures are considered by facilities to be sufficient to confirm the accuracy of the drug and dosage. Therefore, the healthcare professional’s responsibility is not so much to achieve the five rights as it is to follow the facility’s procedures for producing these outcomes. If a problem in the system prevents the procedures from being followed, the healthcare professional must report the problem so that it can be addressed.1
It could be argued that if individuals are held accountable for achieving the five rights, they should have the autonomy to develop their own methods for doing so. In other words, individual healthcare professionals should not be penalized for situations and events that are beyond their control. However, because facilities generally determine the procedures necessary for achieving the five rights and balance those procedures against competing administrative, legal, or financial purposes, staff members must follow the established procedures and should not be held individually accountable.1,4
The five rights should continue to be followed as medication-use goals; however, strong support systems that encourage safe practices must be established in order to help healthcare professionals achieve these goals. Pharmacists can assist in this.
Additional Safety Strategies
Institutional policies concerning medication safety must be followed. As indicated above, it is insufficient solely to dispense the medication as prescribed. Rather, nurses must ascertain that the right medication is prescribed for the right patient in the correct dosage, by the correct route, and with accurately timing (i.e., the five rights). Additionally, it is essential for all healthcare professionals, including pharmacists, to keep abreast of other strategies for preventing or reducing the occurrence of medication errors. The following are other strategies that should be employed.5-7
Medication-Reconciliation Procedures: Healthcare facilities must have procedures for medication reconciliation in place for when a patient is being transferred from one facility to another or from one unit in the facility to another. Each medication—or transfer document listing medications—must be reviewed and compared against the MAR. Additionally, it is extremely important to check with all sources, including the physician, the discharging or transferring facility or unit, and the patient or patient’s family—in order to prevent mistakes due to improper reconciliation.6
Double-Check Procedures: In this process, another nurse on the same shift or incoming shift reviews all new orders to ascertain that each patient’s order is correctly noted and transcribed on the physician’s order and on the MAR or treatment-administration record. Many facilities use a chart-flag procedure to highlight new orders requiring verification.6
Read Back to Another Professional: According to this procedure, a nurse reads back an order to the prescribing physician to ascertain that the medication ordered is correctly transcribed. This can also be performed by two nurses: One nurse reads back an order transcribed to the physician’s order form to the other nurse, who is simultaneously reviewing the MAR to ensure its accuracy.6
Name Alert: Similar-sounding patient names can lead to confusion among nurses and other staff, potentially resulting in medication mistakes. The use of name alerts posted on the front of the MAR can prevent such errors.6
Leading Zero and Decimal Point: A written dosage can easily be misinterpreted if there is no zero before the decimal point (e.g., 5 mg instead of 0.5 mg). This could lead to the patient experiencing an adverse reaction and outcome. A leading zero can prevent a decimal point from being missed.6
Documentation: Accurate drug labeling, legible documentation, and proper recording of administered medications are essential. Failure to document an as-needed medication, for example, can result in administration of another dose by a different nurse since there is no record of the already-administered dose. Another best practice is to review the medication’s prescription label and expiration date. A correct medication can have an incorrect label, resulting in a medication-administration error.6
Proper Medication Storage: Care must be taken that medications requiring refrigeration to maintain their efficacy, such as vaccines, are not kept outside the refrigerator; likewise, those that must be stored at room temperature should be handled accordingly. Most biologics require refrigeration, and multidose vials must be labeled to prevent them from being used beyond the expiration date.6
Medication-Administration Policies and Guidelines: It is important for nurses to be educated about the facility’s medication-administration policy. Frequently, medical policies contain critical information about medication-ordering, transcription, administration, and documentation practices. Nurses also should keep abreast of black box warnings in drug labels, look-alike/sound-alike medication lists, and other guidelines.6
Medication Resources: The use of printed or electronic resources is a matter of preference. Both are equally useful in presenting key information for many drugs, including therapeutic class, trade and generic names, dosing, nursing considerations, side effects, drug-drug interactions, and cautions (e.g., “administer with meals” or “do not crush”).6
The use of any of the above strategies, along with the five rights, can help prevent or reduce medication errors. It is important to remember that a medication error can result in patient morbidity and even mortality. Also, these errors can negatively affect the reputation of a healthcare facility and lead to high institutional and governmental costs.
1. Grissinger M. The five rights: a destination without a map. P.T. 2010;35(10):542.
2. Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Healthcare System. Washington, DC: National Academies Press; 2000.
3. Levett-Jones T, Hoffman K, Dempsey J, et al. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today. 2010;30(6):515-520.
4. Denham CR. TRUST: the 5 rights of the second victim. J Patient Saf. 2007;3(2):107-119.
5. Bates DW. Preventing medication errors: a summary. Am J Health Syst Pharm. 2007;64(14 suppl 9):S3-S9.
6. Vickerie D. 10 strategies for preventing medication errors. https://minoritynurse.com/10-strategies-for-preventing-medication-errors. Accessed May 19, 2020.
7. Thompson C, Dalgleish L, Bucknall T, et al. The effects of time pressure and experience on nurses’ risk assessment decisions: a signal detection analysis. Nurs Res. 2008;57(5):302-311.
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