November 21, 2017By Dr. Kim Baily

The 5, 6, 7, 8, 9 Rights for Medication Administration During Simulation

According to Agency for Healthcare Research and Quality, adverse drug events (ADEs) account for 700,000 emergency department visits and 100,000 hospitalizations each year. In addition, approximately 5% of hospitalized patients experience an ADE each year.  Simulation offers a wonderful opportunity for hospital staff and students to practice the essential skills involved in medication administration. Nursing schools and hospitals typically use a standardized sequence of checks to guide staff and students through the complex process of medication administration. Initially five considerations or rights were identified. Over the years however, additional steps have been added. Some institutions combine one or more of the steps.

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Perhaps the “right reason” should be the place to start. After all, why go through the other rights only to discover that a prescribed medication does not make any sense for a particular patient and the prescriber needs to be contacted to confirm that the drug is appropriate.

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The original five were:

  • Right patient
  • Right medication
  • Right dose
  • Right route
  • Right time

Additional 5 rights:

  • Right documentation
  • Right reason
  • Right  response.
  • Right to refuse
  • Right education.

Simulation for novice learners should follow a standard pattern until they become comfortable with the basics of medication administration. If you are offering simulation for multiple groups, repeating the same scenario with the same group or challenging more advanced learners there are a myriad of ways to add changes to a standard scenario. The list below offers some suggestions.

  • Right patient
    • Change the name band e.g. date of birth or medical record number.
    • Make patient unable to respond to patient identifiers
    • Remove the wristband.
  • Right reason
    • Add medications that make no sense for a patient. E.g. blood thinners or steroids or bury a reason in the patient’s history.
    • Add a medication that a patient takes at home for a diagnosis not on the patient’s chart.
    • Have a patient request a med they usually take at home but is not on the order sheet e.g. thyroid replacement..
  • Right medication
    • Check the MAR against the order sheet (change one or the other).
    • Fill the medication cassette with the wrong drug with a similar sounding name.
    • Mix up the generic and trade names.
    • Include medications that require two checks.
    • Include medications that have Black Box Warnings.
    • For medications such as blood pressure medications with parameters, make the parameters too low so that the medication should be held.
    • Include drug with known interactions.
    • Add a medication the patient is allergic to.
    • Have someone keep interrupting provider while med being drawn up.
  • Right dose
    • Check the MAR against the order sheet (change one or the other).
    • Order an inappropriate dose e.g for the patient’s size or age.
    • Some medications have different doses depending on the diagnosis, prescribe the wrong dose
    • Have the wrong dose in the medication cassette.
    • Have an inappropriate dose for the ordered route.
    • Leave the dose off the original order.
  • Right route
    • Have the wrong route on the order.
    • Confirm that the patient can take or receive the medication by the ordered route e.g. include a large potassium pill for a stroke patient with swallowing difficulties.
    • Make the patient unable to take the medication e.g. because of emesis.
    • Record the place an injection was given, note if the learner checks to see where frequently given injections have been noted.
    • Leave the route off the original order.
    • Have the IV site look swollen and red.
  • Right time
    • Put the wrong scheduled times in the MAR
      • Too frequent doses
      • Doses that need to be taken in relation to meals or other medications
        • E.g. fast acting insulins or meds that are affected by antacids.
      • PRN meds – have the MAR with a recent dose.
      • Have the patient request that the meds be put on the bedside table and they will take after breakfast.
  • Right documentation
    • Provide a method for the learners to chart after the medication was given.
    • Provide a space for learners to record required parameters e.g. blood pressure for antihypertensives.
  • Right response
    • If your scenario is long enough or you time forward, show the response to the medication either appropriate or not:
      • Allergic reaction (can be immediate)
      • Change in VS – within desired range or undesired.
      • Pain medication does not work.
  • Right to refuse/education.
    • Have the patient refuse a medication – the learner will have decide how to continue.  Have the patient refuse because of a lack of understanding about the medication’s purpose.  If the learner explains the reason for the med, have the patient change their mind and take the medication.
    • Have the patient refuse a med for a valid reason.
    • Prescribe a new med for the patient and have the learner teach the patients about the new meds.

Simulation provides a unique opportunity for learners to improve their clinical judgement and prevent patient harm.

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Today’s article was guest authored by Kim Baily PhD, MSN, RN, CNE, Simulation Coordinator for Los Angeles Harbor College. Over the past 15 years Kim has developed and implemented several college simulation programs and currently chairs the Southern California Simulation Collaborative.

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