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McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 9th Edition

Chapter 09: Safety and Quality

Key Points

The “five-plus-five” rights of medication administration are important goals for medication safety. The nurse following these guidelines will give (1) the right patient (2) the right drug in (3) the right dose via (4) the right route at (5) the right time.

The “plus five” refers to the five additional rights that have been recommended: (1) right assessment, (2) right documentation, (3) the patient’s right to education, (4) right evaluation, and (5) the patient’s right to refuse. The right patient determination is essential.

The right patient determination is essential. The Joint Commission (TJC) requires two forms of identification before drug administration.

The nurse must accurately determine the right drug prior to administration.


When working with an EHR, once the bar code on the patient’s wristband has been scanned, the patient’s drug profile will appear on the computer screen.


The nurse will then scan the patient’s medication label, and it will automatically validate the time, date, and the nurse administering the patient’s medication.


If it is not the correct medication, the nurse will receive an alert and will be unable to proceed in the MAR until the correct medication is scanned.

It is the nurse’s responsibility to administer the drug as ordered by the provider, and if the drug order is incomplete, the drug should not be administered. Verification of a questionable order must be done in a timely manner.

Nurses are legally liable if they give a prescribed drug and the dosage is incorrect, or if the drug is contraindicated for the patient’s health status.

The right dose refers to a verification by the nurse that the dose administered is the amount ordered and that it is safe for the patient for whom it is prescribed. The right dose is based on the patient’s physical status.

The right time is the time the prescribed dose is ordered to be administered. Every drug cannot be given exactly when ordered; therefore, health care agencies have policies that specify a range of times within which drugs can be administered before or after the appointed time.

The right route is necessary for adequate or appropriate absorption. The right route is ordered by the health care provider and indicates the mechanism by which the medication enters the body.

The nurse determines if the drug is safe to administer according to the drug’s pharmacodynamics (action) and the patient’s vital signs.

Renal and hepatic functions are important considerations because many drugs are cleared through the kidneys and metabolized by the liver.

Prior to drug administration, it is important that the nurse carefully review the patient’s

most current lab results.

The right time refers to the time the prescribed dose is ordered to be administered.

The right route is necessary for adequate or appropriate absorption. The right route is ordered by the health care provider and indicates the mechanism by which the medication enters the body.

The right assessment requires the collection of appropriate baseline data before administration of a drug.

The right documentation requires the nurse to immediately record the appropriate information about the drug administered. This includes (1) the name of the drug, (2) the dose, (3) the route, (4) the time and date, and (5) the nurse’s initials or signature. Documentation of the patient’s response to the medication is required with a variety of medications.

The right to education requires that patients receive accurate and thorough information about the medication and how it relates to their particular condition. Patient teaching also includes therapeutic purpose, expected result of the drug, possible side effects of the drug, any dietary restrictions or requirements, skill of administration, and laboratory test result monitoring.

The right evaluation determines the effectiveness of the drug based on the patient’s response to the drug. Evaluation in this context asks whether the medication did for the patient what it was supposed to do.

The patient has the right to refuse the medication, and it is the nurse’s responsibility to determine the reason for the refusal, explain to the patient the risks involved with refusal, and reinforce the important benefits of and reasons for taking the medication. When a medication is refused, the refusal must be documented immediately, and follow-up is always required.

The nurses’ six rights are (1) the right to a complete and clear order; (2) the right to have the correct drug, route (form), and dose dispensed; (3) the right to access to information; (4) the right to policies to guide safe medication administration; (5) the right to administer medications safely and to identify system problems; and (6) the right to stop, think, and be vigilant when administering medications.

In addition, the American Nurses Association (ANA) published a bill of rights for nurses in 2015 that contains seven premises concerning workplace expectations and environments that nurses from across the United States recognize as necessary for safe nursing practice. The Bill of Rights supports nurses in workplace situations and includes issues such as unsafe staffing, mandatory overtime, and health and safety issues in the workplace.

A medication error may be defined as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient.”

The ANA supports the concept of Just Culture in its position statement (2010), and it encourages organizations to avoid using punitive approaches in reporting drug errors because they focus on punishing individuals for reporting such errors. In a Just Culture, individuals would be encouraged to report drug errors so the system can be repaired and the problem fixed. A Just Culture does not hold individual practitioners responsible for a failing system, although it does not tolerate disregard for a patient or gross misconduct.

Most organizations have a risk management department staffed with nurse managers and risk managers who conduct root cause analysis (RCA), a method of problem solving used to identify potential workplace errors. Such analysis presents opportunities for learning and focuses on strategies that can be put in place to correct problems.

If a patient dies as the result of a drug error, it is called a sentinel event.

The National Patient Safety Goals (NPSGs) focus on problems in health care safety and how to solve them.

When a prescription drug is known to be effective for some patients but may cause serious side effects in others, the FDA will require the drug’s printed materials to carry a warning about the adverse effects surrounded by a black box.

Drug reconciliation is an important component of the culture of safety. It is defined as the process of identifying the most accurate list of all medications that the patient is taking at transitions in care, which includes admissions and discharges from a hospital to another health care setting such as long-term care.

The Secure and Responsible Disposal Act encourages both public and private entities to develop secure, convenient, and responsible methods for collecting and destroying medications and controlled substances.

The Needlestick Safety and Prevention Act (NSPA) requires that employers implement safer medical devices for their employees, provide a safe and secure workplace environment with educational opportunities, and develop written policies to help prevent sharps injuries.

Every year in the United States, 1.5 million preventable drug errors occur. Data support that a hospitalized patient is subject to one medication administration error per day.

The majority of medication errors occur in the transcription stage (56%), followed by the nurse administration stage (41%), and finally the doctor prescribing stage (39%).

Counterfeit drugs look like the desired drug but may have no active ingredient, the wrong active ingredient, or the wrong amount of active ingredient. Improper packaging or contamination can also be problems.

Although some drugs can be used crushed, some should not be crushed; do not crush any extended- or sustained-release drugs because this will change the pharmacokinetic phase of the drug.

High-alert drugs can cause significant harm to the patient. If a high-alert medication is given in error, it can have a major effect on the patient’s organs.

Nurses should be aware that certain drug names sound alike and are spelled similarly.

Creating a distraction-free environment is critical to safe administration of medications.

In 2015, the FDA replaced the lettered pregnancy categories A, B, C, D, and X on prescription drug labeling. The FDA decided that the previous lettering did not effectively communicate the risk a drug may have during pregnancy and lactation and in females and males with reproductive potential.

The new labeling system provides a broader explanation based on current available information of the benefits and risks medications can have to the mother, the fetus, and the breastfeeding child.