The "five rights"

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It's likely that most healthcare 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.