Better Practices Using 5 Rights to Reduce Medication Administration Errors

Agenda and Outcomes

One recommendation for reducing pharmaceutical errors and harm is to apply the five rights. Medication errors put patients in grave danger. Health practitioners, mainly nurses, are accustomed to the ‘five rights’ of drug use; the exact patient, medicine, time, dosage, and route. These criteria are considered safe medication practices, but they offer little guidance to medical professionals on ensuring drug safety. This paper analyzes evidence-based strategies, improvement plans, and existing organizational resources to discuss the five rights in medical safety. The five rights can help with medical safety concerns, showing that many people and systems are involved in proper drug administration.

When the patient’s name and room number are obscured, and the physician’s signature is illegible, it is difficult for the pharmacist to identify the correct patient. Pharmacists can struggle to find a follow-up contact, and it is unclear if patients are reliable information sources. In many cases, relying on patient information led to mistakes, such as mispronounced names or misunderstanding room numbers. This study examines better practices using five rights to reduce medication administration errors and the organizations implementing them.

Safety Improvement Plan

According to numerous studies, falls are the leading cause of injury deaths in people over 65, even from small heights. This causes bruises, fractures, and internal bleeding (Nordberg et al., 2021). Most falls were caused by slipping or inattention, causing the above health issues. In interviews with nurses, it was discovered that older people fall from the bed while sleeping or waking up, which contributes to their traumatic injuries. Personal factors like anger or excitement also contributed.

The entire medical team should collaborate to prevent falls and achieve positive patient outcomes. Examples are oral education or handouts explaining the prescription’s use, dose, expected benefits, and possible side effects. Patients should be able to ask questions and reaffirm their understanding of proper medication use (Centers for Medicare and Medicaid Services, 2021). Document and discuss allergies with the patient. A list of any other medications the patient is taking should be kept for personal use and displayed at each visit. Family members who help the patient with medication may assist the patient use the drug correctly. It is important for the organization to address the current situation to improve patients’ quality of life.

Audience’s Role and Importance

Nurses and other medical practitioners can be held liable for the following actions:

  • Label reading.
  • If needed, request a second opinion.
  • Questioning illegible or unsafe drug orders.
  • If possible, use barcodes.

Organizations consider these standards sufficient to verify the correct medicine and dose. The practitioner must follow the organization’s processes to realize the five rights. If systemic problems prevent healthcare professionals from following procedures, they must report them. It is hard to hold people accountable for things they cannot control. Businesses determine the processes needed to achieve the five rights, so employees who follow them should not be held personally liable for negative outcomes. The five rights are goals for accepting responsibility and developing fail-safe methods.

New Process and Skills Practice

Physicians and other health care providers must know the medications available to treat their patients to improve medication safety. There are numerous options for doing so, including Computerized Physician Order Entry (CPOE). Orders organized in a computer system are uniform, legible, and complete. To maximize its benefits, CPOE should include clinical decision support. Combining it with clinical decision support systems (CDSS) can reduce medication errors (Nordberg et al., 2021). A medical knowledge base, patient data, and an inference engine create case-specific advice. Whether non-automated or automated technologies are used, patients must order drugs. Clinicians should ensure patients understand the prescription’s medical issue. The teach-back method asks patients to express their understanding of pharmaceutical usage back to the healthcare professional in their own words.

Modern literature offers specific opinions on medical safety issues. Patel and Wright (2018) affirms that safe drug practice provides minimal direction to medical providers on the right technique to guarantee medication safety. Information is vital in the healthcare industry, where people’s lives and health are at stake. To ensure drug safety and prevent adverse outcomes, clinicians need clear guidelines. The information problem also refers to patients’ willingness to provide information to their doctors and nurses (Patel & Wright, 2018). Patients who lie or conceal parts of the truth endanger their safety, but healthcare professionals must also address the issue and prevent it.

Soliciting Feedback

Unsafe pharmaceutical practices and medication errors cause injury and unnecessary harm worldwide. Globally, drug errors are estimated to be worth $42 billion. Medication administration errors can happen anywhere. Several strategies to reduce medication errors have been developed, but implementation varies. The third Global Patient Safety Challenge is to reduce severe, preventable medication-related harm by half in the next five years (World Health Organization, 2019). Below are some of the WHO’s Global Patient Safety Challenges:

  • High-risk drug safety.
  • Safe polypharmacy.
  • Medication safety during care transitions.

Although health organizations exist, they are not the most successful. The number of people suffering from illnesses is increasing every day. There should be several organizations to combat disease, as one is not enough. There should be associations that aim to cure people of all races and nationalities. The WHO is an excellent alternative but insufficient to achieve total disease control. Every country must join efforts to create one global health authority. There are developments in this plan, such as health ministries approaching WHO, but this is not enough as there is no unity, and such requests can cost the lives of many patients.


The five rights are not the final point in world medicine’s structure, but they are still developing. Managers frequently reprimand health care workers who violate the five rights without addressing the underlying human issues. Regulatory authorities penalize health care practitioners who cannot verify the five rights, perpetuating the assumption that individuals are at fault. To help practitioners achieve the five rights, we must develop robust support systems that promote safe practices. All team members must avoid or limit interruptions to the nurse preparing or delivering medications. No distraction zones warn colleagues not to interrupt healthcare providers preparing or administering medications. Do not disturb signs over medication preparation areas or healthcare providers’ colored vests during medication administration.


Centers for Medicare and Medicaid Services. (2021). E-prescribing.

Nordberg, S. S., McAleavey, A. A., & Moltu, C. (2021). Continuous quality improvement in measure development: Lessons from building a novel clinical feedback system. Quality of Life Research, 30(11), 3085-3096.

Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), S16-S17.

World Health Organization. (2019). Medication safety in transitions of care

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