Sometimes the five rights make us look dumb

[JBMmom]

Do you REALLY ask every patient to state their name and date of birth before every medication that you administer? I was doing it for a while, and I always prefaced it with "for your safety, can you please state your name and date of birth", check against the wrist band and go on. Part of my problem is that I work nights, and sleep is hard enough to come by in the hospital as it is. But, early on, I had a few patients respond with different variations of "how dumb are you that you can't remember who I am?" And I see their point. Once we've done the initial identification, and they haven't even moved out of bed, I am pretty sure that I can identify them accurately- at least for the next eight hours, and especially when I've had them 5 days in a row. Additionally, I've got some patients on antibiotics spaced two hours apart all night- I can scan their bracelet, the IV bag, and start it without even waking them, so the name and date of birth part- not so much happening every time. I've got an orientee now, and I want to set someone else off on the right track, so I just want to know how others practice. And what are your thoughts on balancing common sense with the by-the-book safety aspect.

[TriciaJ, RN]

The first 5 Rights were very reasonable for their time, and are still relevant. Everything else is just...yet another embarrassment.

What foolishness some of these are.

One wonders why we must always move toward ridiculousness and excess rather than reason and equilibrium.

I suspect it's because people often skip the steps. When errors happen, TPTB think the steps are inadequate and add more. When I worked med-surg my patients often told me I was the only one that checked the wrist band. I thought they must just not be noticing when other nurses do it. I mentioned this to a coworker and she said "No, I hardly ever check the wristband." It floored me because she is a conscientious nurse. Or I thought she was.

[neuron]

I don't really care if I look stupid, I ask them to state their last name if I'm giving a med and if there is a doubt. Sometimes even if you given the patients meds 5 x, they sometimes look like another patient, have the same last name, but different first names...etc. Sometimes I'll even ask to see if they are competent.

[elkpark]

I think there's a false assumption that these sorts of habitual routines reliably improve safety, when they often do the opposite. When something becomes too routine it no longer improves safety, I've seen nurses ask a patient their name and birthday out of habit, all the while not actually making a conscious check of this against the MAR. This is why ISMP has recommended that excessive use of double checks be avoided, it only weakens the effectiveness in terms of safety when it's overused.

Yes, but the reason the double identifiers were instituted in the first place was because too many nurses had become complacent about being confident they knew who was who. We keep putting these kinds of higher demands into place to avoid errors made by people not being alert and careful, and then the kind of people who tend to not be alert and careful quickly become inured to the new safety feature, as well.

Like when they added the additional, higher brake light on the back of cars because too many people weren't paying attention to the existing brake lights. I remember predicting, when those became a new thing, that the kind of people who weren't paying attention to the existing brake lights quickly won't notice the new, additional brake light, either. If the US required car manufacturers to make cars with a neon sign that took up the entire back window of the car and lit up to say, "Hey, stupid, I'm braking" when you stepped on the brake, there are people out there who would quickly stop noticing that, too.

I recall reading an article many years ago about how the rule about no abbreviations in medical orders came about. It was implemented as a safety feature after an RN put IV potassium solution into someone's eyes and blinded the individual. The problem was supposed to be that she was confused by the abbreviations in the order. In order to have instilled the potassium solution into the client's eyes, she had had to draw up the solution from a vial with a syringe. I say, if you're so dumb or complacent that you don't immediately recognize that there's something seriously wrong with having to draw up the supposed "eye drops" from a vial with a syringe, the abbreviations in the chart ain't the problem. But, now, no more abbreviations -- and, yet, med errors are still happening.

IMO, the problem isn't the number of "identifiers," it's people not being alert and cautious. (But that's not an excuse for not following the established rules and procedures.)

[ruby_jane, BSN, RN]

The right position? I'm coming up empty on what this could be in reference to. If a med is supposed to be given with the patient in a sitting position?

Lovenox and insulin are also positional. As are vaccines...pharmacist giving me a flu shot was waaay high last year and I said something....

[klone, MSN, RN]

The first 5 Rights were very reasonable for their time, and are still relevant. Everything else is just...yet another embarrassment.

What foolishness some of these are.

One wonders why we must always move toward ridiculousness and excess rather than reason and equilibrium.

IK,R?

Right to refuse? That's just dumb. That's a different type of "right". Next thing you know, they're going to say one of the rights is "Write it down afterwards" or "Rite of documentation"

[Guest219794]

Eight Rights of. Medication Administration.

The Right Person.

The Right Medication.

The Right Time.

The Right Dose.

The Right Route.

The Right Position.

The Right Documentation.

The Right to Refuse.

But the OP while calling this one of the five rights is really asking about patient identifiers. We are required to use two patient identifiers when passing meds - Since I work with psych patients I usually go with their name and photo I also check the armband.

Hope this helps

Actually, it is up to ten now:

The Right Person.

The Right Medication.

The Right Time.

The Right Dose.

The Right Route.

The Right Position.

The Right Documentation.

The Right to Refuse.

The Right License.

The Right Indication.

The right license is critical- With medications being given by various levels of license or certification, this is critical. Somebody qualified to give tylenol may not be qualified to push propofol.

The right indication: A pt with PRN benadryl for itching should not be given benedryl for sleep.

Back to the OP- The five rights don't make us look stupid.

The concept of the "right patient" is just that- Give the medication to the right patient. How you confirm that may be determined by your personal practice, or facility policy. And yes, that can be frustrating to the patient.

Regarding the last two rights: As part of a national initiative to make life harder for nursing students, I have given myself the authority to add to medication rights. Why not? These guys did.

[Nurse Beth, MSN]

The key should be verifying "2 patient identifiers" (which is on the armband)

and not asking the patient. TJC and CMS require 2 identifiers, but are not prescriptive as to the method.

A policy that mandates asking the patient cannot be followed consistently. Think newborns, unconscious patients, non-English speaking, ventilated patients.

[hppygr8ful, ASN, RN, EMT-I]

The right position? I'm coming up empty on what this could be in reference to. If a med is supposed to be given with the patient in a sitting position?

Right position could be just that - Fosomax for instance needs to be administered with the patient sitting upright in a chair and they must remain seated for 1 hour after administration. Also when giving an IM that requires a big muscle what position should the patient be in to receive it.

Hppy

[dream'n, BSN, RN]

The five rights have served me well for years and years. Don't think I'll be memorizing the 7,8,or 14 rights; seems like overkill.

[MunoRN, RN]

Yes, but the reason the double identifiers were instituted in the first place was because too many nurses had become complacent about being confident they knew who was who. We keep putting these kinds of higher demands into place to avoid errors made by people not being alert and careful, and then the kind of people who tend to not be alert and careful quickly become inured to the new safety feature, as well.

Like when they added the additional, higher brake light on the back of cars because too many people weren't paying attention to the existing brake lights. I remember predicting, when those became a new thing, that the kind of people who weren't paying attention to the existing brake lights quickly won't notice the new, additional brake light, either. If the US required car manufacturers to make cars with a neon sign that took up the entire back window of the car and lit up to say, "Hey, stupid, I'm braking" when you stepped on the brake, there are people out there who would quickly stop noticing that, too.

I recall reading an article many years ago about how the rule about no abbreviations in medical orders came about. It was implemented as a safety feature after an RN put IV potassium solution into someone's eyes and blinded the individual. The problem was supposed to be that she was confused by the abbreviations in the order. In order to have instilled the potassium solution into the client's eyes, she had had to draw up the solution from a vial with a syringe. I say, if you're so dumb or complacent that you don't immediately recognize that there's something seriously wrong with having to draw up the supposed "eye drops" from a vial with a syringe, the abbreviations in the chart ain't the problem. But, now, no more abbreviations -- and, yet, med errors are still happening.

IMO, the problem isn't the number of "identifiers," it's people not being alert and cautious. (But that's not an excuse for not following the established rules and procedures.)

I agree that the problem is complacency, and an over-reliance on habits that don't by themselves provide safety is a big source of this complacency. These processes only work when there is active thinking going on, and too often we suppress active thinking with these habits once they become too routine.

[MunoRN, RN]

Actually, it is up to ten now:

The Right Person.

The Right Medication.

The Right Time.

The Right Dose.

The Right Route.

The Right Position.

The Right Documentation.

The Right to Refuse.

The Right License.

The Right Indication.

The right license is critical- With medications being given by various levels of license or certification, this is critical. Somebody qualified to give tylenol may not be qualified to push propofol.

The right indication: A pt with PRN benadryl for itching should not be given benedryl for sleep.

Back to the OP- The five rights don't make us look stupid.

The concept of the "right patient" is just that- Give the medication to the right patient. How you confirm that may be determined by your personal practice, or facility policy. And yes, that can be frustrating to the patient.

Regarding the last two rights: As part of a national initiative to make life harder for nursing students, I have given myself the authority to add to medication rights. Why not? These guys did.

There are sources that claim there are 14 rights of medication administration. The whole point of the "5 rights" is that there is a need to identify a small group of high priority considerations when giving a medication, whomever these people are that are coming up with these longer lists clearly doesn't understand the point of these safety precautions.

1. Right Drug/Medication

2. Right Client/Patient

3. Right Route

4. Right Dose

5. Right Frequency/Time

6. Right Assessment

7. Right Approach

8. Right Education

9. Right Evaluation

10. Right Documentation

11. Right to Refuse

12. Right Principle of Care

13. Right Prescription

14. Right Nurse Clinician

[RNrhythm, BSN, RN]

When I was asking for name and DOB again, the patient said, "Honey, maybe you should write this down."