The Five Rights: A Destination Without A Map
It’s been 8 years since we’ve written about the shortcomings of relying on the five rights of medication use in this newsletter (The “five rights,” April 7, 1999). When we first brought our views to readers, we stressed that the five rights are not the “be all that ends all” in medication safety. They are merely broadly stated goals or desired outcomes of safe medication practices that offer no procedural guidance on how to achieve these goals. Thus, simply holding healthcare practitioners accountable for giving the right drug to the right patient in the right dose by the right route at the right time fails miserably to ensure medication safety. Adding a sixth, seventh, or eighth right (e.g., right reason, right drug formulation, right line attachment) is not the answer, either.
We also pointed out that the five rights fail to acknowledge that human factors and system weaknesses contribute to errors, and that the focus of the five rights on individual performance does little to reflect that safe medication practices are a culmination of both interdisciplinary efforts of many individuals and reliable systems.
Despite these shortcomings, ‘failure to follow the five rights’ is still often cited as a performance deficit when a medication error occurs, clearly perpetuating the mistaken belief that healthcare practitioners can be held individually accountable for achieving these goals. To be clear, nurses and other practitioners cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights.
For example, nurses cannot really verify the right patient if they have no way of knowing whether the patient is who they say they are, whether the name on the arm band is accurate, and so on. They can only verify two unique patient identifiers assigned to the patient upon admission—a process the organization deems to be ‘enough’ to satisfy that this is the right patient—before administering medications. Likewise, nurses and pharmacists cannot really verify that the right drug is provided in a given tablet or vial, or that it contains the right dose/strength. But they can be held accountable for reading the label, requesting an independent double check if required, questioning orders for drugs/doses that are illegible or appear unsafe, using bar code technology if functional, and so on. These are procedural steps the organization has deemed sufficient to verify the right drug and the right dose. Thus, the healthcare practitioners’ duty is not so much to achieve the five rights, but to follow the procedural rules designed by the organization to produce these outcomes. And if the procedural rules cannot be followed because of system issues, healthcare practitioners also have a duty to report the problem so it can be remedied.
While some may think this distinction is minor, consider the following. If we hold individuals accountable for achieving the five rights, we really should give them the authority to design their own systems for achieving these outcomes. After all, how can we hold individuals accountable for things that are not under their control? However, since organizations typically decide the processes that are necessary for achieving the five rights, individuals who follow these processes should not be held individually accountable for an undesirable outcome. Improvements must be made in the systems designed to achieve the five rights, not in the individual’s practice or behavior. The five rights are not a behavioral model for achieving medication safety, but goals for which organizations must accept responsibility and design failsafe ways that they can be achieved.