Please, please, please remember the 5 rights! - Page 3

Except she said that the syringe HAD been clearly labeled, with the name of another patient (and, presumably, the drug name, since the nurse handing the empty syringe over knew what it was). The nurse didn't READ the thing before injecting the wrong child.

Negligence, clear and simple.

Please remember that now there are 6 rights of medication administration. They added documentation to the original 5!

Pssst! Pipe:


Massachusetts Nurses Association - Nursing Resources - Nursing Practice - Nursing Issues - Nurses' Six Rights for Safe Medication Administration.



Guideline #5: General Procedures for Medicataion Administration



Medication Administration: The 6 R's

Six Rights of Medication Administration

Ashley, PICU RN,

You know... Them! haha

I actually can't tell you came up with it originally. All I know is that anyone who leaves out magic #6 and ends up in court will be a prosecutor's dream!

one would think after having the 5th or the 6th embedded in our brains during our nursing program, we would put it into practice for once & for all and not take it for granted....just saying~

you know what? this may astonish you, but this would never go to trial because there was no damage done. no atty will take it. the kid's fine. no damages, no suit. remember, you need to have all the components for a malpractice action to succeed.

there must be a duty to care; in this case, the pharmacist and the nurse had a duty to care for this child at their hospital
there must be a breach of duty; in this case, the care given was not to standard (the wrong med dispensed; the nurse did not check it)
there must be damages: an injury suffered or some sort of loss (and this is where this one loses it, because the kid is, thankfully, fine)
the breach of duty had to have caused the damages. (dumb luck here)

so. the board of nursing is not bound by the same legal standard, and if they want to burn this nurse's butt, they have what they need to do it: evidence of unsafe practice. i must say if i sat on that board, i would vote for butt-burning in a heartbeat. this is no unavoidable system failure. she didn't read the label, or if she did, she didn't know what she was reading. and it had another kid's name on it, besides.

don't know about the pharmacy board, but i imagine they might have something to say to the pharmacist about dispensing carefully. perhaps the or had just called for some vercuronium and he was expecting someone to come and get it, and only later realized this was not the right med...and may have thought, "i screwed up and gave it to the wrong person, but the syringe is labeled properly, so the nurse will catch it." a not unreasonable assumption, btw. so alas, in this case, yes, imho it is all on the nurse.

and i always told my students the 6th right was "right indication," as in, "you'd better know why you're giving that, and if it's unsafe, you'd better speak up."

That sounds horrible. I can imagine how furious the parents of the little boy were and how terrified the nurse was. Thank you for sharing the experience. This is a great reminder for all of us to always check whatever medication we give to patients.

Thank you SOOO much for posting this. As a RN student who will graduate soon these real world experiences are the VERY BEST teachers. I will remember this story every time I administer a medication. I'm so glad the child didn't suffer any long-term effects...I'm sure the nurse who made the error will, I know I would. THANK YOU

I could not agree more. I'm still a student, but in my clinical setting last semester I was given a flu vaccine to administer to my patient. When I went to check it against my MAR I realized the syringe was not labeled. I went back to the RN who pulled it for me and told her I did not feel comfortable administering an unmarked medication. She was extra annoyed that she had to go back to the med room and pull another, but then she realized that NONE of them were labeled. They came up from pharmacy that way apparently. My instructor was very happy with my handling of the situation and not backing down from the RN who really did try to intimidate me into just giving the med...shame on her right?