The "five rights"
From the April 7, 1999 issue
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
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.