The Five "Rights"

The Five "Rights"

THE FIVE "RIGHTS"

This article appeared
in "ISMP Medication Safety Alert!"--April 7, 1999, a newsletter published
by the Institute for Safe Medication Practices, and circulated to members of
the healthcare community. Reprinted with permission.
It's likely that most health care professionals,
especially nurses, have learned about the "five rights" of medication
use: the right patient, drug, time, dose, route. They're generally regarded
as a standard for safe medication practices. Still, many errors, including lethal
errors, have occurred in situations where practitioners firmly believed they
had verified the "five rights." Why does this happen? First, the "five
rights" are goals of safe medication practices. As such, they offer little
procedural guidance (how to) to practitioners during medication use. For example,
how does a pharmacist identify the "right patient" when the patient's
name and room number on an order copy are blurred and the physician's signature
is illegible? Who does he call for follow-up? How does a home care nurse providing
care in an assisted living facility identify the "right patient" when
name bracelets are not used? Can she depend on verbal questioning, which has
led to errors when names were misheard or patients were confused? Without adequate
systems in place to help practitioners achieve the goals of the "five rights,"
errors are likely.
Further, the "five rights"
focus on individual performance and do not reflect that safe medication practices
are a culmination of multidisciplinary efforts where responsibility for accurate
drug administration lies with multiple individuals and reliable systems to support
safe medication use. For example, poor lighting, inadequate staffing patterns,
poorly designed medical devices, handwritten orders, trailing zeroes, ambiguous
drug labels and lack of an effective double check system for high alert medications
can contribute to staffs' failure to accurately verify the "five rights,"
despite their best efforts.
Finally, the "five rights"
do not take into account the significant contribution of human factors to errors.
For example, human factor researchers have demonstrated that "confirmation
bias" causes practitioners to misperceive important information in their
environment. As a result, professionals who select the wrong product, with a
label or package similar to the correct product, often will say that they looked
at the label to verify the "right drug." In truth, they may have even
read it carefully. However, they did not "see" it correctly. We "see"
with both our eyes and our mind. While our eyes, with proper eyesight, have
the capacity to take in all information, our mind learns to screen out information
that it considers less useful, to prevent information overload. Additionally,
as we gain experience, we develop a picture in our mind of items in our environment.
Thus, as we attempt to locate or recognize items through comparison with our
mind's picture, often we are unable to see any disconfirming evidence if the
wrong product is selected. Instead, we see what we intend to see. The ability
to filter information and locate or recognize items using a picture in our mind
is vital to correct performance. Yet, it contributes to errors when our fallible
minds make corrections for what our eyes are actually seeing.
The "five rights" are not the
"be all that ends all" in medication safety. Unfortunately, many times
management staff may simply admonish practitioners who make an error for not
following the "five rights," without recognizing or addressing the
human factors and system-based causes. Likewise, regulatory agencies often sanction
practitioners based on their lack of verifying the "five rights,"
thus perpetuating the belief that individuals should be blamed and punished.
While the "five rights" should remain as medication use goals, we
must help practitioners achieve these goals by establishing strong support systems
that encourage safe medication practices.