Wednesday, December 5, 2007

Best Practices for Nurses in Maintaining Safe Medication Administration by Practicing the "5 rights" of Medication Administration.

A medical mistake made at a Methodist hospital in Indianapolis was reported again in California at the Cedars Sinai Medical Center. In the California pediatric unit, the three infants got an adult dose of Heparin, a blood thinner.

That's 10,000 units instead of the infant dose of ten. “It's the same mistake that led to the death of three young patients in the NICU at Methodist hospital last year (Tiernon, 2007)”
Ongoing research shows that medication errors are happening frequently and that adverse drug events, or injuries due to drugs, occur more often than necessary. According to Kaufman (2006), at least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications (para.1). Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day as he or she occupies a hospital bed (Kaufman, 2006, para.2). Medication administration errors are not only harmful and widespread but also very costly. "The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be 3.5 billion a year” (Kaufman, 2006, para.4). The errors indicate a breakdown in the system. Nurses should carefully practice the “5 rights” of medication administration in order to provide safe medication administration. The “5 rights” of medication administration are: Right patient, right route, right time, right drug, and right dose.

Meadows (2003) noted that the National Coordinating Council on Medication Error Reporting and Prevention defines a medication error as “any preventable event which may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health-care professional, patient, or consumer" (para.4).According to Stoppler (2006), a study by the Food and Drug Administration evaluated reports of fatal medication errors from 1993-1998, “the most common error involving medications was related to administration of an improper dose of medicine, accounting to 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications.”In addition, many medication names look or sound like other medication names, which may lead to potentially harmful errors. Examples of medications that look and sound alike include: Amaryl and Reminyl, Clonidine and Klonopin, Depakote and Depakote ER, Famitidine and Furosemide, Xanax and Tenex. "An 8-year old died, it was suspected, after receiving methadone instead of methylphenidate, a drug used to treat attention deficit disorders.A 19-year-old man showed signs of potentially fatal complications after he was given clozapine instead of olanzapine two drugs used to treat schizophrenia. And a 50-year-old woman was hospitalized after taking flomax, used to treat symptoms of an enlarged prostate, instead ofvolmax, used to treat bronchospasm. In each of these cases reported to the Food and Drug Administration, the names of the dispensed drugs looked or sounded like those that were prescribed” (Rados, 2005).
To provide safe medication administration, the nurse should carefully practice the “5 rights” of medication administration. First, the nurse should ensure that the medication is given to the right client by checking the client’s identification bracelet and having the client state his or her name. The nurse should never go by room and bed number alone. “Some clients answer to any name or are unable to respond, so their identification should be verified each time a medication is administered. The nurse should verify the client by checking the identification bracelet. Some facilities put the client’s photo on his or her health record. The nurse should distinguish between two clients with the same last name” (Kee & Hayes, p.24)."Children are not totally reliable in giving correct names on request. Infants are unable to give their names, a toddler or preschooler may admit to any name, and school age children may deny their identification in an attempt to avoid the medication. Children sometimes exchange beds during play. Parents may be present to identify their child, but the only safe method for identifying children is to check their hospital identification band with the labeled medication or medication card" (Wong & Perry, 2002,p.1156). According to Kee & Hayes, in settings such as schools, physician’s office, and outpatient departments where clients do not wear identification bands, it is the nurse’s responsibility to identify accurately the individual when administering medications.
Second, the nurse should ensure that the medication is administered via the prescribed route. “The common routes of absorption are oral (by mouth), sublingual (under the tongue), inhalation (aerosol spray), suppository, (rectal, vaginal), buccal (between gum and cheek), via feeing tube, instillation (in nose, eye, ear), topical (applied to skin), intramuscular (IM), subcutaneous (SC), intradermal, and intravenous (IV)” (Kee & Haye, 2006, p.26).The oral route is preferred for administration of medication to clients whenever possible because of the ease of administration of oral medications. However, whichever route is prescribed, the nurse needs to make sure that the route is accessible. For example, if a medication is to be given by mouth, can the patient swallow? If not, can the medication be crushed? Third, the nurse should administer the medication at the time the prescribed dose should be administered. “Daily drug dosages are given at specified times during the day, such as twice a day, three times a day, four times a day or every 6 hours, so that the plasma level of the drug is maintained” (Kee & Hayes, 2003, p.26). Drugs with a long half-life are given once a day whereas drugs with a short half-life are given several times a day at specified intervals. In addition, drugs that are prescribed in association with meals need to be given with meals.In addition, the nurse should administer the right drug. This means the client receives the drug that was prescribed. To do this effectively, the nurse should check the medication order against the medication. If the order is illegible or some components of the order are missing, such as signatures, the nurse should contact the health care provider.
Furthermore, the nurse should administer the right dose prescribed for a particular client. The nurse should check the order and the medication label and look up any medication which he or she is not familiar with. The nurse should calculate each dose accurately, and ensure that each dose is within the recommended dose for the particular drug. Mayor (2004) states that “training and assessment of competence in pediatric drug therapy- including calculations of doses and infusion rates should be introduced to reduce the risk of drug errors in children.”
In conclusion, medication errors are surprisingly common and costly to the nation. They can lead to prolonged hospital stay, unnecessary diagnostic tests, unnecessary treatments, and death. Nurses can help to decrease the prevalence of medication errors by carefully practicing the “5 rights” of medication administration. Nurses can maintain patient safety by administering the right medication, in the right dosage, to the right client, by the right route, and at the right time.

Kaufman, M. (2006, July 21). Medication Errors Harming Millions. The Washington Post. p. A08. Retrieved February 19, 2007 from
Kee, L.J., & Hayes, R.E. (2003). Pharmacology. A Nursing Process Approach (4th Ed.). Philadelphia, PA: W.B.Saunders Company.
Mayor, S. (2004). Report Calls for Strategies to Reduce Medication Errors.British Medical Journal 328:248 .7434.248-b . Retrived May 20, 2007 from
Meadows, M. (2003).Strategies to reduce medication errors. FDA Consumer Magazine. Retrieved, February 14, 2007 from Rados, C. (2005). Drug Name Confusion: Preventing Medication Errors. Retrieved, May 20,2007 from .
Stoppler, C.M. (2006). The Most Common Medication Errors. Retrieved, May 20, 2007 from
Tiernon M.A (2007). Families upset over new Heparin overdose cases. Retrieved, December 3, 2007 from
Wong, D., Perry,S. & Hockenberry, M.J. (2002). Maternal Child Nursing Care. (2nd Ed.) St. Loius, MO. Mosby-Year Book, Inc.

A: Intervention # 1: Incomplete and illegible orders

Disadvantage # 1: Sometimes physicians write incomplete orders with either the drug, dose, route, and frequency missing from the order. All of these components must be present for a physician order to be considered complete. It is not a good practice to accept orders when the dosage is written as "1 tablet." "A complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be specific and the dose explicit (Cook, 2007)."

Disadvantage # 2: At times physicians write illegibly making it difficult for the nurses to read and transcribe orders correctly. Some facilities such as The Massachusetts Hospital Coalition recommends physicians use computers to directly order medications. "However, such costly systems may take years to implement.Cefoxitan and Cefotetan may look alike when hand written but confusing one drug for the other results in the patient receiving the wrong medication (Cook, 2007)."

B: Intervention # 2: Knowledge deficit

Disadvantage # 1: "Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication." However, not every family, nursing facility or clinic have drug guides. The package insert that comes with every medication is also a good resource but yet due to language barrier, inability to read and comprehend medical terminology, some patients or nurses may not be in a position to give the right dose, of the right drug, at the right time. Pharmacists are knowledgeable resources and can answer many questions regarding medication but this may not be the case for over-the-counter medications (Hauswirth, 2002).

Disadvantage # 2: At times nurses have minimal or no knowlege of calculations leading to the right dosages. "Calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams (Hauswrith, 2002).


Cook C. Michelle (2007). Nurses' Six Rights for Safe Medication Administration. Retrieved November, 7 2007 from Katherine Hauswirth (2002). Administration of medication. Gale Encyclopedia of Nursing and Allied Health, 2002. Retrieved November 7, 2007 from

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