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feature article

Patient Safety
Examining the Adequacy of the 5
Rights of Medication
Administration
MARILYN MACDONALD, PhD, RN

urpose: The purpose of this article was to examine the adequacy of the 5 rights (5 R ’s) for
P nurses and for including patients in medication administration while considering patient
safety. Patient safety related to medication adverse events will be discussed; the 5 R ’s will be
examined and critiqued and the importance of patient-centered care and patient par-
ticipation in care will be presented. A path forward is offered based on the expressive-
collaborative model. Suggestions for introduction of the model are outlined, and implications
for practice, research, and education are discussed. Background: Nurses have been guided
by the 5 R ’s of medication administration in both education and practice for many decades.
Many have found the 5 R ’s to be lacking and proceeded to propose the addition of a variety of
rights from right indication to the rights of nurses to have legible orders and timely access to
information. Patients are no longer passive recipients of care and are choosing to play
increasingly greater roles in the process of care. Innovation: In a collaborative patient-
centered environment, an expressive-collaborative model of approaching systems of care is
needed. In this model, individuals negotiate with one another to find out what people need to
know and to strategize on the means to acquiring the necessary information. Providers are no
longer expected to be all knowing. Conclusion: Medication administration is no longer simply
the 5 R ’s. Medication administration is a process with many interconnected players including
patients. We need to collaboratively restructure medication use in this era in which all in-
volved in the process share the responsibility for a safe medication use system.
KEY WORDS: expressive-collaborative model, medication 5 rights, patient centered

P atient safety is a current national and international priority, with medication safety
designated as both a widespread and risk-producing area of concern.1–5 Medication
safety requires the integrity of a complex series of interrelated steps, such that failure to

Author Affiliations: School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada.
Correspondence: Marilyn Macdonald, PhD, RN, School of Nursing, Dalhousie University, 5869
University Ave, Halifax, NS, Canada B3H 3J5 (marilyn.macdonald@dal.ca).

Clinical Nurse SpecialistA Copyright B 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

196 CLINICAL NURSE SPECIALISTA

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
adequately assess, prescribe, dispense, consume, and moni- a result, a failure to learn and to understand the cause of
tor medications can potentially lead to adverse events and many errors.20
harm. For decades, nurses have practiced the 5 rights (5 R’s) The limitations surrounding sole reliance on the 5 R’s for
of medication administration6: right patient, right drug, medication administration have been recognized for some
right dose, right route, and right time, as a process to mini- time, and efforts have proceeded to augment the 5 R’s in
mize risk of error in medication administration. The 5 R’s of 2 ways: first, by adding additional rights and, second, by
medication administration were developed for use by nurses, proposing rights for the nurse administering the medications.
and consequently, the role of the patient in the medication Suggestions that have been made in terms of augmenting the
administration process has only recently been considered. 5 R’s include right indication, right documentation,21 and
Increasingly, hospitalized patients want to play a greater right equipment.22 Cook23 proposed a series of rights for
role in their treatment and care and see a role for themselves nurses that included the right to have legible orders, correct
in medication administration.7 The purpose of this article drug dispensing, timely access to information, procedures in
was to examine the adequacy of the 5 R’s for nurses and for place to support medication administration, the time it takes
including patients in medication administration while con- to safely administer medications, and problems addressed in
sidering patient safety. Patient safety related to medication the medication administration system.
adverse events is discussed. The 5 R’s are examined and Work interruptions during medication administration are
critiqued. The importance of patient-centered care and patient also known to be a source of medication errors. The number
participation in care is presented, and a path forward is of interruptions is estimated to be 6.7 per hour.24 A recent
offered based on the expressive-collaborative model of ethical review of the literature on interruptions revealed that a more
reasoning. Finally, suggestions on the introduction of the precise definition of interruptions is necessary and that nurses
model are offered, and implications for practice, research, themselves initiated most of the interruptions.24 Clearly, in-
and education are discussed. terruptions need to be reduced.
For a decade, the Institute for Safe Medication Practices25
has written about the shortcomings of the 5 R’s process and
PATIENT SAFETY AND MEDICATIONS
the inadequacy of simply adding rights to the existing pro-
Compromised safety in medication management can be cess. The Institute for Safe Medication Practices points out
extremely costly to patients, health care professionals, and that verifying a patient armband does not guarantee that the
the health care system.5,8,9–11 A recent report on medication armband belongs to the person wearing it and that the
safety concluded that approximately 1.5 million preventable medication in the bubble pack is what is written on the label.
adverse drug events occur per year, resulting in a total cost The lesson in this work is that medication administration is
of US $3.5 billion.12 Similarly, as many as 1 in 5 Canadian part of a complex system of care delivery and that all aspects
patients admitted to the hospital experienced adverse events of the system must be functioning properly to minimize the
at the point of discharge home, and 66% of these were chance of error during the delivery of patient care.
medication-related events.13–15 Medication-related events Nurses themselves realize that the medication adminis-
are estimated to cost Canadians $750 million.16 A study of tration process is much more than the 5 R’s. The 5 R’s are
Halifax, Nova Scotia, seniors found that as many as 1 in initiated at the point of medication administration; however,
11 experienced a preventable drug-related morbidity over a a host of actions occurs well before this step including
2-year period.17 Moreover, patients also recognize problems checking medication orders, following up with pharmacy on
with the manner in which medications are provided to them. missing medications, and assessing the patient.26 The lit-
In the 2003 Commonwealth Fund Survey, 11% of patients erature makes it abundantly clear that the process of medi-
in Canada reported that they had been given the wrong cation administration is a complex one, one in which all
medication at one time or another.18 systems of an organization must be properly functioning,
and one in which the professionals need adequate time and
resources. The ultimate aim in the medication administra-
CRITIQUE OF THE 5 R’S
tion process is to safely administer medications to patients.
Nurses administer the majority of medications in hospitals. Despite this, there is a lack of consideration of the role of the
The standard most frequently referred to guide the medi- patient in these processes. Not only has the manner of look-
cation administration process is that of the 5 R’s as de- ing at medication errors shifted from individuals to systems,
scribed above. Following the 5 R’s implies that a medication but also the care provider is no longer seen as solely re-
error will not occur. However, clinicians, researchers, and sponsible for the well-being of the patient.
administrators realize that adherence to the 5 R’s is not a
stand alone process. Furthermore, a considerable volume of
PATIENT-CENTERED CARE
literature exists on the inadequacy of relying on the 5 R’s.
Most medication errors occur at the points of ordering Patients are not passive recipients of health care. In 1998,
(39%) and administering medications (38%).19 the Canadian Institute for Health Information spearheaded
The 5 R’s were established in an era when the paradigm a consultation process to determine patient health informa-
guiding care delivery held individuals solely responsible in tion needs. Consumers were included in this consultation,
the event of any type of error in care delivery. The context in and one of the priorities advanced from this initiative was
which care was delivered remained unexamined. Gradually, the distribution of health information to consumers (www.
clinicians and researchers came to recognize that this cul- cihi.ca).27 Knowing this, the Canadian Patient Safety
ture of blame did little to address the occurrence of errors Institute has included the involvement of patients as a
and in fact resulted in a failure to report errors and, as priority area for research.2 One of the priorities identified by

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Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Canadian Patient Safety Institute related to patients is the documents is the elaboration of the factors that silence the
patient role in safety. patient voice and how to banish the silence.
In 2002, citizens from the United States formed the Con- Partnering with patients to conduct research about
sumers Advancing Patient Safety.28 This organization con- patient safety is congruent with a patient-centered philoso-
sisted of patients’ family members who had experienced loss phy and with the tenets of primary health care and health
as a result of adverse events. Today, this organization exists promotion outlined in the Ottawa Charter.35 Central to the
to provide consumers a voice regarding health care safety Charter is the message that health systems must reorganize
and the ability to serve as a resource for care delivery cen- in such a way as to ‘‘share power with other sectors, other
ters to become more patient centered (www.patientsafety. disciplines and most importantly with people themselves’’(p427)
org). and that health is not the sole responsibility of the health
Within the Canadian context, a 2002 survey of patient care provider and the health care system. Recently, in a
views on the patient-provider relationship found that more study on the perspectives of patients and nurses on the role
than 50% of patients believe they have the primary re- of the patient in medication administration safety,7 partici-
sponsibility for decisions regarding their health. An addi- pants confirmed that they saw a role for patients in medi-
tional 35.6% expect decision making to be shared between cation administration even if the role was limited to the
themselves and their health care provider.29 patient (who is able) verifying with the nurse that the medi-
Canadian patients seek and expect to receive information cations about to be ingested were in fact what they usually
regarding their health condition.30 Because safety is an inte- take.
gral part of health care, involving patients in issues related A medication reconciliation safety initiative is under
to their own safety presents as one means of reorganizing way across North America. This initiative involves the
services so that the power to provide safe health care is verification of a patient’s medications upon admission or at
shared. In support of this statement, the World Health triage in an emergency department and at every care
Organization World Alliance for Patient Safety launched an transfer point. This initiative is a good example of a
initiative in 2004 to coordinate global and national efforts strategy to engage patients in their care. The only way that
to improve patient safety. The World Health Organization reconciliation will work is if the initial medication history is
World Alliance for Patient Safety stressed that patient, accurate,36 and this means the person interviewing the
family, and citizen perspectives must be central to patient patient must minimize the provider-patient authority
safety.31 Most regional, national, and international confer- gradient so that patients sense that they are trusted and
ence programs now include testimonials from patients and respected. This trust and respect enable patients to be
families about individual adverse events. forthcoming about what medications they really do take,
Further evidence of a shift in thinking from provider-only how much, and how often.
solutions to consideration regarding patient involvement in
safety has come from the literature on patient-centered care.
Much has been written about patient-centered care, and 3 INCONGRUENCE BETWEEN 5 R’s AND
robust documents are briefly described here to illustrate this PATIENT-CENTERED CARE
shift in thinking. They are the (1) Registered Nurses of
The 5 R’s were introduced to the medication administration
Ontario’s32 Best Practice Guideline on Patient-Centered
process at a time when the health care provider was deemed
Care; (2) American College of Critical Care Medicine’s33
the expert in illness and treatment related matters. Learning
Clinical Practice Guideline for Patient-Centered Intensive
about medication administration following the 5 R’s is no
Care Units; and (3) Picker Institute and Commonwealth
longer adequate. Nurses take the medication administration
Fund–sponsored report on patient-centered care.34
process much further than simply following the 5 R’s.
Many health care delivery centers describe the care they
Nurses have identified the importance of teaching patients
provide as patient centered. Patient-centered care encom-
about their medications and the need for patient involve-
passes respect for human dignity, the belief that patients are
ment in the medication administration process when
experts of their own lives, and respect for patient goals. Pa-
possible.7 Nurses collaborate with physicians and pharma-
tient care based on values of continuity, consistency, time-
cists on an ongoing basis regarding medications. Many
liness, responsiveness, and universal access will also be safe
patients want to be more involved in the decision making
care (Registered Nurses of Ontario).32 Asking patients and
around their medications as well as all aspects of care.
families about what they want and how they see their health
Nurses, physicians, and pharmacists have an opportunity to
care is part of patient-centered care.
explore with patients, approaches to medication adminis-
The American College of Critical Care Medicine’s Clini-
tration that incorporate a systems approach, and interpro-
cal Practice Guideline outlined how providers need to act in
fessional patient-centered medication administration. A variety
relation to patients and families in all aspects of their care.
of theories were considered to guide such an initiative, and
This guideline strongly supports including patient and
a theory based in ethics was selected for its relevance to all
family perspectives and the inclusion of patients and families
involved.
in the decision-making process.
The Picker Institute and Commonwealth Fund report on
patient-centered care outlined the attributes expected in a
FROM 5 R’s TO PATIENT CENTEREDNESS
patient care environment, one of which is the involvement of
patients and families. The author explained that this involve- Traditional ethical models such as the theoretical judicial
ment must be provided at multiple levels from the bedside to model37 of thinking predominated throughout much of the
developing policy. What is absent from these important 20th century. Our society is stratified by sex, class, race, age,

198 CLINICAL NURSE SPECIALISTA

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
education, and many other layers of power and status. Be- The major challenge to model implementation identified
cause of these layers, members with health and medical was the engagement of all involved, to trust in the process
backgrounds perceive situations differently from those with- and to be willing to keep working at the process to get it
out a health care background. According to the theoretical right. This means entry into a process of creation of a dif-
judicial model, those with power and status were considered ferent way of being and doing. This process is not efficient
to be all knowing and decided what was best for all in- in the short term, and this is particularly challenging for
volved, in this case, health care. In the past, the views of individuals who seek early results.
patients and families were largely discounted, as well as
the context of their lives, in decisions regarding care and
medication administration. EXPRESSIVE-COLLABORATIVE MODEL AND
CLINICAL NURSE SPECIALIST PRACTICE
EXPRESSIVE-COLLABORATIVE MODEL The skills necessary for incorporating this model into clini-
cal nurse specialist (CNS) practice involve perception,
An ethical model that embraces patient-centered care is the discussion, and responding, all of which the CNS role em-
expressive-collaborative model.37 This model is a philosoph- braces. Practicing within the model necessitates an ability to
ical model that takes a moral view of life, with a particular respond sensitively in feeling and behavior, an ability to
focus on sharing responsibility among human beings. The clearly describe and explain activities and situations, an
skills necessary to enact the model are perception, discussion, appreciation that each person has a level of knowledge and
and ability to respond. This model invites individuals to ex- understanding, and the ability to establish some basis of
amine the moral view of life that we hold and to what extent moral equilibrium with patients. The model represents a
we expect patients to act in a particular way, and how pa- way of thinking about how we (nurses) are in relation to
tients are judged if they fail to do so. Moral equilibrium is the patients; if we believe that we know best, then disequili-
goal, related to beliefs, perceptions, expressions, judgments, brium results and the likelihood of patient participation in
actions, and responses. Tolerance will not do; ultimately, any aspect of their care is reduced.
mutual respect is desired via a consensual process. Patients The CNS is constantly consulted in situations that prove
need to be considered as full moral agents, and traditional to be clinically and interpersonally challenging and is ideally
moral understandings such as the complete authority of pro- suited to identifying situations in which the moral wishes of
viders over medication administration are questioned. the patient have not been respected. This model offers the
This model advances that all human beings carry moral CNS a way forward in these situations. The challenges to
identities shaped by the lives we have lived, and these identi- CNS practice in embracing the model are to recognize that
ties are imbued with moral judgments. These judgments may many of the health care providers they work with may be
extend to how we believe the patients we care for should holding firmly to the theoretical judicial model. Engaging
look, act, be, and do. The model encourages us to examine everyone involved in a collaborative process means bringing
the moral view of responsibility that we hold, to reflect on together individuals with dissenting points of view and fa-
the extent to which we expect patients to act in a particular cilitating a group process that seeks balance over compli-
way, and to recognize provider tendencies to locate failure in ance necessitating skills in handling conflict and discord.
patients forgetting there is a level of shared responsibility. The CNS as facilitator also needs to be a reflective prac-
Patients need to be considered as full moral agents; tradi- titioner and to guard against unduly influencing the process
tional practices such as health care providers having com- because of a particular personally desired outcome.
plete control over medication administration are questioned.
Moral order is necessary and always present. It is the disequi-
librium in the order that the model seeks to address. In this INTRODUCING THE
model, individuals negotiate with one another to find out EXPRESSIVE-COLLABORATIVE MODEL
what each other need to know and how to go about finding
out what they need to know. In this model, one size does not This model has the potential to frame the way entire health-
fit all; rather, each person is considered to have a level of related organizations operate. Organization-wide implemen-
knowledge and understanding that is valued, and health pro- tation all at once is not recommended because the model is a
fessionals will tap into this and work with the person collab- process of creation and as such needs to happen in one
oratively to determine how a course of treatment is to unfold. setting at a time. The CNS is ideally suited as the individual
Application of the model was not found in the nursing to introduce use of the model one situation at a time, and as
and health-related literature but rather in the education liter- those involved experience the process, a change in thinking
ature,38 where the administrative and educational challenges and approach will begin to occur one person at a time. Once
as well as the strategies for implementation were discussed. the model has been successfully used in a variety of situa-
A central administrative challenge was the existence of the tions and settings and those involved believe in the process,
theoretical judicial model and the enactment of a certain then consideration can be given to wider implementation of
‘‘moral’’ order in schools. Educators and administrators spent the model in other settings.
significant amounts of time determining a code of conduct
for students. Introducing the expressive-collaborative model EXPRESSIVE-COLLABORATIVE MODEL, 5 R’s,
necessitated broad consultation with all involved, increasing
AND SAFETY
the likelihood of students self-managing the agreed-on be-
haviors and leaving administrators and educators time for One can see how the establishment of the 5 R’s for nurses
doing direct administrative and educational activities. to administer medications made sense in the era of the

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Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
theoretical judicial model. Medication administration was will also need to be introduced into programs for nursing
seen as a single act performed by a nurse and not as part of education.
a larger system. Today, we know that the main players in
medication administration (physician, nurse, pharmacist,
CONCLUSIONS
patient) are intricately interconnected; each has a stake in
making sure that the medication administration system Medication administration is no longer simply the 5 R’s.
functions effectively. This will require each player respec- Medication administration is a process with many inter-
tively and collaboratively identify and articulate the pro- connected players including patients. We need to collabo-
cesses necessary to ensure system integrity, and each player ratively restructure medication use systems in this era in
needs to know and understand the processes of all players. which all involved in the process understand respective roles
Patients are the newest players in this process and as such and share the responsibility for a safe medication use
will need considerable mentoring by those familiar with system. The proposed revision to the medication admin-
medication use systems. The health care provider team and istration process is not simply adding a step or two to an
the patient will ultimately formulate what the next iteration existing process, but rather, a rethinking of attitudes and
of the 5 R’s will be; however, small examples of revisions to actions on the part of each person involved in the medi-
existing processes may include requiring patients where cation use system. The hope is that, by each participating
appropriate to identify the medications they are about to person, viewing the medication administration process in a
take and the indications for the medications. Pharmacy may new way that gains can be made in making the process more
consider issuing where appropriate a medication adminis- responsive and safer for all involved.
tration record to the patient for their reference and to
promote patient self-management of medications.
The challenge is shared by all involved in medication References
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