Five Rights of Medication Administration 1

Five Rights of Medication Administration Matthew Mabalot HTM 680 National University

Five Rights of Medication Administration 2 Five Rights of Medication Administration Patients deserve and are entitled to receive the safest and appropriate care from medical staff including accurate medications. The rights of the patients are described as The Five Rights of medication administration which are 1. Right Patient, 2. Right time and frequency of administration, 3. Right dose, 4. Right route of administration, and 5. Right drug. Each of the rights are important to understand in the case study Childrens Hospital and Clinics which discuss how the patient safety initiative came about and why identifying the risks are important in medication administration. The Harvard case study on Childrens Hospital discussed the stories of patients who were misdiagnosed and overdosed on medication because of medical errors. The study described how medication administration at Childrens at system failures that caused these events to happen. Julie Morath was the COO at Childrens created the patient safety initiative. She voiced her case by stating 98,000 people died annually from medical errors which easily caught the attention of every staff member. Focus groups and the Patient Safety Steering Committee were developed to study and report events to help improve the processes and prevent future events such as these from occurring. One of the stories was the patient named Matthew who was overdosed because the nurse did not see the label on the medication which indicated the amount of morphine levels. The patient almost died of an overdose because of system failures. The case study was about discussed how this incident created the patient safety initiative to help prevent this from happening again. The Five Rights of medication administration were very important in the events that happened in the past in hospitals because of lack of risk assessments and technology. Technology helps hospitals identify the correct patient is being treated, scheduling of medications, routing patients to the correct department, filling the correct prescription, and giving patients to correct dosage for medication. The case study involved health care staff and patients to report on these events to make a difference the next time around. Instead of blaming staff on every incident that occurred, Morath created a blameless reporting system that let staff report on incidents that happened and could be improved if identified.

Five Rights of Medication Administration 3 Focused events studies and safety action teams developed during the patient safety initiative implementation which helped Childrens Hospitals acknowledge the need for patient safety improvements. The good catch logs were also created to report on processes that can be improved before incidents can occur. Risks can be identified by understanding the five rights of medication administration and relating it to risk mitigation. The focus groups, safety reports, safety action teams, and good catch logs are a great way to identify the risks and implement a risk analysis. The risks associated with medical administration include misdiagnosing, overdosing, medical equipment failure, incorrect patient, and drugdrug interactions. The process of preventing risks from happening is identifying risks, managing the risks, prioritizing, evaluating, and risk-reducing controls. The risk mitigation includes risk assumption, risk avoidance, risk limitation, risk planning, and acknowledgement. The first risk of misdiagnosing can potentially happen when information is limited and tests were not analyzed correctly. The likelihood of this risk would be low and can be controlled by identifying the patients history and symptoms. Reporting documents and recording medication should be inputted into an EHR system to reduce the likelihood of happening. The case study discussed of the child who was misdiagnosed and died. This risk of misdiagnosis is high priority because it can cause deaths. The likelihood of misdiagnosing seems low but is a lethal threat. The risk of overdose is a highly impacted risk and controls should be evaluated diligently. The likelihood of overdose happening is high because of lack of information showing on labels and unavailable at the time of need, according the Childrens Hospital case study. All of the risks identified are highly impacted in the consequences if the incidents occur. Medical equipment failure should be tested for vulnerability by inspecting the equipment and studying the use of equipment on patients. Managing the potential risks of equipment failing or finding more quality equipment to safe lives is a priority in the risk mitigation. Lethal drug-drug interactions are a high likelihood risk of happening if EHR was not utilized at the time.

Five Rights of Medication Administration 4 Risk mitigation approaches can be used to prevent the incidents from occurring in the future. First is to identify all the risks and its vulnerability, find the recommended controls for the risks, and prioritize the risks from highest to low. Risk for overdosing should be prioritized as then number 1 risk to likely happen if not controlled immediately. Preventing lethal drug should be placed next on the priority action list and the recommendation control is utilizing an EHR system to identify and alert medical professionals when these incidents can occur. The case study Childrens Hospital and Clinics is a huge eye opener in the improvement of health care delivery. The medication administration and the Five Rights are so important in our health care system because it is a matter of life and death. The stories of the case study reflect how badly medical errors can cause harm to patient when not acknowledged. Often times, people do understand the medical errors that occur but no actions are taken because of fear of being blamed for them and not understanding the lives they actually affect. The risk of medication administration is different in children hospitals than adult hospitals is somewhat more life changing. The thought of any child in danger because of system failures or medical staff incompetence is a parents biggest fear. Children are not fully developed to be able to survive these types of errors that can occur compared to adults. Patients should always have the right to know when something goes wrong or why it went wrong. It is a lot harder to accept a death or a horrible outcome that happens to a child than to an adult. It is important to find these flaws in health care with children because the children are our future of preventative care. Adult medication administration is different because adults have the ability to speak up or can be more aware and children are considered innocent. The last thing a sick patient needs is a threat of their safety from the medication administration. If we can reduce risks with children, it will be easier to reduce with adults. As humans, we all react more and take actions when children are involved.

Five Rights of Medication Administration 5 References

A. Edmondson, M. Roberto., A. Tucker (2007).HARVARD BUSINESS CHOOL (9-302-050). Childrens Hospital and Clinics (A) G. Stoneburner, A. Goguen, and A. Feringa. (2002). NIST. Technology Administration of U.S. Department of Commerce. Risk Management Guide for Information Technology Systems. Recommendations of National Institute of Standards and Technology. Retrieved from http://csrc.nist.gov/publications/PubsSPs.html#800-30.