Accepted Practice

Six Rights

Learning to prepare and administer medications safely and accurately is an essential component of your nursing practice. It requires that you follow your facility’s policies and procedures carefully and always perform three checks on the first five of the six rights of medication administration: the right drug, the right dose, the right route, the right time, and the right patient. Be sure to document the procedure.

The right drug


Determining that you have the right drug involves checking the medication label against the medication administration record (MAR) at least three times before you administer the drug. The exact times you perform these three checks depend on how the drug is stored and your facility’s policy, but in most situations you would check as you remove each drug from the storage area, as you prepare each drug, and at the patient’s bedside before you administer each drug. In addition to checking the label against the MAR to make sure you have the right drug, check also that you have the right dose, are planning to give it by the right route, and that it is the right time. Verify the drug’s expiration date at this time as well.

 

The right dose


Many facilities use a unit-dose system to help reduce the risk of medication errors. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double-check your work before you give the drug. Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants.

When administering oral medications, it is sometimes necessary to give only a portion of a tablet. To break a scored tablet in half, use a cutting device to improve accuracy. If the tablet does not break evenly, discard it, if your facility’s policy allows it, and cut another tablet. If it is a controlled substance, follow your facility’s policy for discarding these drugs. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. Policies about this practice vary widely, so be sure you understand what your facility requires should this situation arise. Some might allow this practice only in the pharmacy, for example, or might prohibit nurses from dividing unscored tablets.

If a patient is unable to swallow pills, you might have to crush a medication and mix it with food or a beverage before administering it. Use a crushing device, such as a mortar and pestle. When mixing the medication, use the smallest amount of food or fluid possible. Because medications can alter the taste of food, avoid mixing it with the patient’s favorite foods and beverages as this might diminish the patient’s desire to eat or drink them.

Whenever you cut or crush a medication, clean the pill cutter or mortar and pestle before and after use. It is a good practice to check with a pharmacist or a drug guide before cutting or crushing a medication. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed.

The right route


The route you will use to administer the medication is indicated on the drug order. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification. When giving an injection, verify that the preparation of the drug is intended for parenteral use. If you inject a preparation not intended for parenteral use, complications can result. Most drug manufacturers label parenteral medications “for injectable use only” to help prevent errors, so check the label carefully.

The right time


Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as “hour of sleep”). Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible. Some drugs must be given around-the-clock to maintain a therapeutic blood level. Other drugs should be given during the patient’s waking hours to allow uninterrupted sleep. Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h). Most facilities also have a policy indicating how soon before or how long after the scheduled time a drug can be administered. For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time.

In certain situations, medications must be administered at times other than those indicated by the facility’s time schedule. For example, a preoperative medication might be ordered to be given “stat” (immediately) or “on call” (right before a procedure). When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time. For example, when a pain medication is ordered q4-6h, assess your patient’s pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer. The following is an example of a medication administration schedule.

The right patient


Before giving a medication, make sure that you are giving it to the right patient. You must use two identifiers. For example, check the patient’s medical record number on the medication administration record against the patient’s identification band and ask the patient to state his or her full name. In some facilities, an electronic scanner will be used to match the patient’s medication administration record with the identification band. If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patient’s identification band. If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patient’s identification band. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient.

The right documentation


Accurate documentation must be available before and after a drug is administered to ensure that it is prepared and administered safely. Medication orders should clearly state the patient’s first and last name, the name of the drug ordered, the dose, the route, the time the drug is to be administered, and the signature of the prescriber. If any of this information is missing, notify the prescriber before giving the medication. After you give a medication, place your initials in the designated space by the medication as soon as possible to indicate that you gave the dose. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well.

Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error.