How important the 3 checks of 5 rights are for meds!!!

  1. I have just finished my 5th qtr of ADN and we caught wind of a 6th qtr ADN student who was going through her preceptorship and made the near fatal mistake. She gave the wrong pt the wrong meds, multiple meds at that. The pt almost died and is still in ICU. She was kicked out of the entire program, and it is believed that she will not be able to obtain a licenses ever (not sure the license part is true). I don't know what happened, why she didn't check the 5 rights, or what her excuse was. At this point I don't think it matters what her excuse was.
    I felt very sick to my stomach when I heard this. Many things ran through my head; how does she feel after going through all this hard work only to majorly screw it up, OMG what about the pt and their family, how could something like this happen, where was the nurse who was precepting her?
    I just want to take this time to remind everyone that the nursing field is not a place to ever feel too comfortable and start to slack!!!

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    About FE710

    Joined: Jan '09; Posts: 27; Likes: 8
    from US


  3. by   DAMomma
    Thanks!!! As an RN of 4 months, no matter how busy or how many pts I have, I ALWAYS stop and do my checks no matter what. Even for a Tylenol, I take my sheets in the room, looking at ID bands, looking at all identifiers. Talking to the pt about the med. It gives me a piece of mind at the end of the day.

    Thanks again for the reminder!
  4. by   casi
    Ouch. Thanks for that reminder.
  5. by   Daytonite
    how important the 3 checks of 5 rights are for meds? the nursing field is not a place to ever feel too comfortable and start to slack!!!
    i was a staff nurse, supervisor and manager over my 30 years of work as an rn. at every job orientation the medication rights were reviewed with us before we even went out on our clinical units to begin giving medications. no one monitors your individual behavior and it is up to each of us to do what is right and what we learned in nursing school. many, however, get frustrated, or listen to the bad advice of others and begin to cut corners so that their practice gets sloppy. you begin to think you recognize medications because you have memorized what they look like or the packages that they come in. when i worked in nursing homes we memorized the med orders of the patients because they seldom changed so some stop looking at the medication sheets and mew drug orders get missed plus many nurses never locked their med carts since patients weren't wandering in the halls (but other staff were). over the years i've seen nurses get fired for giving the wrong iv meds, nurses and patients who stole from unlocked med carts and were caught, and as a manager i eventually had to fire a nurse who we wrote up several times for leaving medications at bedsides instead of waiting at patient's side while watching patients take them. she kept insisting that there was nothing wrong with that and the director of nursing finally decided that there was something wrong with her and we fired her. when i was a member of a hospital safety committee we reviewed incident report after incident report that were medication errors where there were violations where the 3 checks of the 5 rights had not been done. on each incident report the person was asked how they could have avoided the error and their reply was always that they failed to do the 3 checks of the 5 rights. i was recently flabbergasted by the serious error made by the nurses with the dennis quad twins and heparin. that was a flat out failure to read the label on the vials of heparin before giving the drug to those babies. the hospital tried to cover it all up for the public by blaming it in the bar coding system which is the most ridiculous thing i ever heard of, but i'll bet those nurses didn't get away with explaining it that easily with their supervisors.
  6. by   AOx1
    Many errors are "system errors"- high risk meds being stored on units where they should not be, similar labels, etc. However, to not check the basic rights is just lazy in my opinion. I would not want a nurse that is already this cavalier about following safety rules to care for me. More importantly than how the student feels, think how the patient and his/her family feels, having put trust in a system to provide healing, nearly to be killed.
  7. by   XYcsccSN
    Very important!!! If all three checks are done 100% of the time, medication errors would be nearly zero.
  8. by   tbell2
    I had my own twins in the NICU shortly after the Quaid twins ordeal, and it never left my mind.

    When i was in the hospital (12 days total before and after twins birth) I was surprised at the number of times my band was not checked. There was only one nurse who did it consistently. And for the first few days it was loose and fell off and I just kept it on my table and handed it to them when they asked. Now that I have been passing meds, I know how big of a no-no that is!
  9. by   seniorstudent123
    Let me say as a nursing student who is not practicing on my own yet this scares the hell out of me haha. Medication errors seem to be so common and at least one seems almost unavoidable if you stay in nursing your whole life. My question is what happens after an error is made? Do nurses normally lose their license?
  10. by   ICAN!
    Quote from FE710
    I don't know what happened, why she didn't check the 5 rights, or what her excuse was.
    I start nursing school next month so I am not familiar with the 5 rights. What exactly is this?

  11. by   NC Girl BSN
    Quote from ICAN!
    I start nursing school next month so I am not familiar with the 5 rights. What exactly is this?

    Right Patient
    Right Drug
    Right Dose
    Right Time
    Right Route
  12. by   JBudd
    The 6th right: right documentation. If you don't sign the med as having been given, the pt may get double dosed. If you sign it before you actually give it, and he refuses or you drop it; he is recorded as having gotten something he didn't.

    The other question I've started asking: are you allergic to anything? Several times lately I've gotten, "oh yeah, I forgot to tell them about ........."

    Senior123: no not often. In fact, in order to get med errors reported more consistently, in order to identify system errors that are leading to mistakes with meds, reports are now being done without identifying the nurse. It leads to more reliable and consistent reporting. Loss of license would be for the BON to decide, if there was gross negligence that caused serious harm it may go to the Board; most lessor errors would not be reported outside the facility.
  13. by   RainDreamer
    The 6 rights are important, but mistakes can still happen.

    It's also imperative to look up each medication that you aren't familiar with, to check correct dosing, compatibility, adverse reactions, indications, etc, etc.
    Last edit by RainDreamer on Jun 20, '09
  14. by   rainingwoman
    I didn't check one day, and I was actually kind of out if it that day, and I took the wrong patient's blood glucose. Thank GOD I didn't have any meds, because I know I would probably have given it to him. It was such a bone-chilling thing to realize that I WOULD have, even if I didn't, because I didn't do the 3 checks.