How Many Rules of Medication Administration Should There Really Be?

Oh NO Mr. Bill! Here comes Nurse Kratchet!! Everybody Look OUT!!!
Oh NO Mr. Bill! Here comes Nurse Kratchet!! Everybody Look OUT!!! | Source

What Are the Five Medication Rules?

As a new nurse it was seared into our brains...literally, well OK maybe not seared how bout just slightly singhed?

The five rights or rules of administration of any medication is not just a way to make young nursing students lose sleep trying to figure it out; that is reserved for all the nerves off the vertebrae! No, the med rights I know you guys can still rattle them off.


I'm sorry, was that a mutter of bredom?

I should hope not! Nurse Kratchet is here after all :)

And you know how bad she can get so watch it dudes and dudettes!!! There WILL be a test!

Why Is It Important Anyway?

Giving the wrong medication to the wrong patient is bad enough in itself. This type of medication error can sometimes cause irreversible damage, even fatalities. Take Amoxicillin, a well known antibiotic for young mothers with children prone to ear infections. But give this med to a child who weighs less than the child for whom it was intended and you can be dealing with anaphylactic shock in less than a half hours time.

Giving the incorrect Dosage of the Medication even if it is going into the correct patient can cause the same result. Take Digitalis. Digoxin. Lanoxin. Digitek. This is a cardiac glycoside that works by slowing the rate of the heart so the heart can pump blood and nutrients more effectively. If too much is given then the heart could actually stop.

A lot of medications have alerts for "sound alike" and the problem comes when a sound alike drug is given in place of the one actually ordered as often they are not even in the same class of drug at all! But, we don't allow that to occur because we always read back and even spell back to the physician who is always in a hurry and walking down the hall at the time or in the act of hanging up the phone as we speak. Right?

I realize that the habit of working all the rights/rules of medication administration is a difficult habit to cultivate; the above instance is just one example of how difficult it can be. Nurses have forever relied on our pharmacists to help keep our patients as safe as possible. With the advent of one dose at a time/unit dosing in hospitals and nursing homes it was done first as a way to help prevent errors and to allow the nurse to spend more time at the bedside, a time saving tool. Unfortunately, nurses became complacent and even less informed of what medications they were giving and the side effects, interactions and dosages. We trusted totally that the pharmacist would shield us from any wrong doing.

So, back to Nursing 101 and the five rules of medication administration. From there, I will delve deeper into a soap box (or two) of my own; why documentation of Expiration Dates and Lot Numbers are so important and how many TRUE Rules of MEDS Are There After All?

I beg your pardon? You have to take your break? You did not get the message that this IS a Mandatory In-service? You will be given a ten minute after the next segment so sit tight a while longer.

(speaker thinking to herself "You should have gone before you got here!")

The five Rights of Medication Administrtion

Right Patient/especially important when you are a travel nurse or a per diem nurse who is given responsibility of patents you do not know by sight. Also important if in a nursing home setting the persons in charge of photos Joint Commission state only that there must be at least patient identifiers, neither of which can be the patients room number.All hospitals have a different way to identify patients and be compliant with the JCAHO rules and regulations.

Dose/with the implementation of the PYXIS or unit dose system this should have fixed that problem. HA. What about when the pharmacist brings down the new med cart and half an hour later the physician comes and changes the dosage? We have all had that happen and hopefully knew about in time to call the pharmacy and get the corrected dose before our correct Time was out of compliance!

Time/the time of administration is usually that we have half an hour either way to allow us enough time to get all the medications into all our patients with time to spare. Try working in a nursing home on day shift and see how long it takes to get all 0800 hour meds into all 40 patients before 0900 meds are due then don't forget all blood sugars at 1000 hours then comes 1100 meds then 1200 then 1300 hour meds and finally you have to do all your treatments before 1430 hours when the evening shift shows up. That is a good day. Throw a code into the mix or two discharges and an admit and all bets are off. Nurses who work in that environment have become genius's of invention! By necessity!

Route/we all have seen orders written in error about route. Let's not go into per rectal (snickers and guffaws all around) that is well seated :) in our memories! The ones I laugh at are 'by mouth' orders for patients who have a G or a Peg Tube and have the order for 'Nothing By Mouth!' That takes a presidential order sometimes to get corrected and a line in all your nursing notes stating that "Patient received all meds and feeding per tube related to diagnosis of so and so and supervisor aware of need to correct orders for route in chart" if you were not successful in getting the physician's nurse to call you back before end of your shift so you could write the order to correct it yourself!

Medication/we touched on this briefly at the beginning but again it is imperative that as nurses and professionals we continue to stay educated and aware of new medications, changes to names of medications, medications that are considered "high risk" and the way the medications act,potential side effects, interactions with foods and other drugs and complications to report to the physician.

You may now take a Ten Minute Break!

Break Time Is Over!

It was because I have had the luxury of working in acute care settings as well as in long term care and finally in Home Health especially that I have developed such a strong opinion concerning safety with administration of medications. In the 1980s I worked in Big Fork, Montana at the nursing home. I had the privilege of receiving a wonderful orientation by an older nurse with an army background. She was totally awesome and so patient, so smart and she taught me so much about Geriatric nursing! That first day I had to show up for work at like 0500 hours!!! Bleary eyed and scared I stood there in the med room and doled out one pill at a time into little souffle cups starting with breakfast the mid morning then lunch then 1400 hours. One patient at a time for 25 patients. My supervisor was right next time and she of course had the her 25 patients done in half an hour then she patted me on the back, smiled and said, "Coffee will be ready when you are". Finally at like 0715 hours I got my coffee and watched as my supervisor went over my med board, a thick wooden block with lots of holes cut to just fit a souffle or plastic med cup. I was devastated to see her take out over half!!!!!!! "These are wrong, go back to the med page on each one and see if you can find what the error is. If you can't, then I will help you" So, deep breath, went back, hands shaking with nerves before it was done but I did it all correct that time! I was so proud to see my supervisor smile and pat me on the back and say "Good work, now let's go to work"

That was then. Do you think it helped decrease medication errors? The Government in all it's infinite wisdom did not. Before the end of the 80's unit dosed system came into play and the time spent with the patient went down. So then the RN's were placed at the desk for charting and troubleshooting and sometimes patient care and more nurses were hired to do medications and treatments. That one 50 bed nursing home that ran like clockwork with two RNs on days, one RN and one LPN on evenings and one RN on night shift for decades ended up having to triple their staff to adhere to the new Medicare rules and regulations.

Oh and don't forget the Minimum Data Set also came along at the same time so an MDS coordinator was added to the staff as well!

Along with what many considered a huge mistake (don't say that too loudly,walls and all and ears and all/nuff said?) nurses were given the start of many educational in services concerning medication safety. Along with, of course, the responsibility to document and be aware of all these changes. The first thing I remember having to change was how I assessed and evaluated the effectiveness of pain and pain medications on my patients. You guys know this already, it concerned the zero to ten pain scale. Of course we got it became the nurses way of deciding if the patient had pain or not. If the patient was stoic, no outward look of grimacing or writhing or moaning a lot of times pain medication was withheld!

This happened to my Hubby, great manly man,old Seal and all that he is. He contracted ITTP (idiopathic thrombocytopenia purpura) and had to receive chemo to get his platelet count out of the dirt but he was also in a huge amount of pan! The Chemo nurse would ask what his pain was on a scale of 0-10 and hubby would say "I'm OKAY I can take it" and dude, daughter Katie and I, whichever was with him would FIGHT to get him some comfort! Finally when he went pale and broke out in a sweat the Rn would relent and hopefully took that as a lesson to remember!

Then you guys remember your ADON or MDS Coor or QA nurse would come along every 3-4 days and rake you and your med sheets over the coals to see if you had given any pan meds and if so had you documented in an hour the patients response to that pain medication? All units would send a nurse aide around to all the other med nurses with a whispered "Look OUT!" and we would all scramble to review our PRN Med sheets for please, dude, how ethical did that make us and please tell me how that helped us as nurses learn to assess and eval effectiveness of pain meds?
Taught us how to CYA!

OOPS, probably not the best thing to admit, eh?

So, when the shoe was on the other foot and I was the one perusing the pain med sheets I, inherent there's got to be a better mouse trap than this teacher that I am, started researching, reading, looking for ways other professionals had handled this slippery creature called patient safety goal number one from JCAHO, Patients Pain.

What we all came up with, because after all I did NOT want to do all this by myself :) was a way to make sure all aspects of medications for pain were correctly administered according to the patients goal of how THEY felt comfortable.

This was the first part of the process; getting the little old people to understand that we wanted to keep them comfortable but alleviation of all pain was often impossible without totally having them sleep all the time!

Once that was done we found a lot of our patients had way too many kinds of pain medications on hand! That led to a meeting with the patient, their family members, the pharmacist and the physician and whew! We got our med sheets down to one book instead of two! Who'd have thunk it?

Then came the documentation part which we had already been doing but NOW it was asked of the patient! Even if we had to use resources such as our nurse aides or family members or another nurse walking by, we'd ask in a whisper "hey can you see if so and so is comfortable? Don't wake him/her but if awake get a pain number for my sheet would you?"

It worked like a charm.

So, Is Five Still Applicable?

Remember when alert and oriented times three was changed to alert and oriented times four? The fourth orientation became whether the patient was alert to his/her situation.

It is my opinion, and we know what those are worth and NO I do not want to hear your opinions of My opinion! Settle down there now! I feel there are more than five rules of medication administration and furthermore it is something all of us as nurses have been doing for decades now! We need to add documentation, we're doing it anyway so what's the bid deal?

We need to add assess and evaluate, we are already doing these as well, correct?

That leaves just the patient right to refuse and patient education. Don't give me that deer in the headlight look; you guys are doing this already too!! Tell me you've never had a patient look at the pills in the souffle cup and say "These aren't my pills, what are you giving me?" Sometimes you have to bring in, well actually you should have the plastic Pyxis packets with you at the bedside, cough cough, of course I KNOW you all have that with you to double check the original 5 rules.....OKAY/ Moving on now... and that's an excellent time to instruct on all the meds and how sometimes they look different due to which pharmaceutical company they came from.

By the way guys dont forget to check out HappyBoomerNurse's latest hub on THAT issue!

Sorry, got sidetracked...

And of course upon discharge nurses have to educate patients and families on their discharge meds. Often the hardest thing to get them to grasp is that the discharge list means that's ALL they are to be taking; if they have other meds with other physicians that is the reason for the physicians order to "Follow up with your primary MD within one week" Especially important now that most hospitals have gone to the use of hospitalist physicians and the primary physician may or may not even come to see their patient in the hospital!

OK so you have education down; now let's go to the last (Huge sighs of relief from the audience which I gracefully allow to go unnoticed...well except for a few mental images of I the speaker throwing spit balls towards the back row) rule that needs to be addressed and which we as nurses have already been doing but not taking credit for it!

The patient has the RIGHT to REFUSE!

NO, you cannot crush them all up and put them in pudding without an MD order and patient family permission. This often comes up with patients who are older, confused, have head trauma, strokes or side effects due to pain meds that cause disorientation and change in behavior and mental status.

If the patient is alert and oriented times four and you have correctly assessed and evaluated that fat, what do you do? I smile, educate, cajole, plead. That is it. I do not browbeat or threaten or even frown (note picture at top of this hub ) you can look like that in your head but watch out, thoughts show up FAST and SURE on your face and patients see it and your rapport and trust is ruined forever.

Then you report to your supervisor, the physician, the patients family members and then you document it. That is it. Usually one of the person's you reported to can convince the patient to adhere to the physician orders, however they still have the right to say No.

And that is it folks! All you have been ding and never knew you were actually creating more than the original five rights of medication administration! Aren't you so proud of yourselves! And well you should be! You have used your evidenced based, proven resources and added to what we as professionals have already been doing for many years!

Hats Off To Us!!

How Many Med Rights Have You Come Up With?

Did you come up with more than the original 5 rights of meds after reading this hub?

  • YES, we should add documentation, education,assessment and evaluation and the right for patient to refuse!
  • Are you for REAL? I don't enough time as it is to just put the meds in the patients mouths! What universe are you living in, anyway?
  • Remember, if you answer number two Nurse Kratchet will become your new supervisor :)
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Comments 10 comments

Happyboomernurse profile image

Happyboomernurse 5 years ago from South Carolina

Great hub, written with great humor on a topic that can be a matter of life and death for patients who depend on the nurse getting the 5 medication rules (oops, or is it 10 rules?) right.

Thanks for the shout out for my "Burzynski: The Movie" hub. Dr. Burzynski's excellent documentation skills and practices helped him prevail in 2 lawsuits in which the FDA confiscated every single patient file in his practice. Nurses need to remember that good medication documentation is not only to protect their patients, but it may also protect them if the patient's file ends up in a malpractice lawsuit.

Am rating this hub up across the board!

travel_man1971 profile image

travel_man1971 5 years ago from Bicol, Philippines

I respect the rigors of being a nurse, with all those patients especially at the public hospital.

The loads they've been assigned to affect their services, as well; while entertaining questions from non-medical persons, especially family members of patients admitted in the medical facility.

Not to mention when there's a medical operation going on.

When I was a radio reporter, the head nurse will know that I was present because I've been sneaking to the recuperating rooms where I interviewed victims of domestic violence more often.

Another burden for a nurse-on-duty. Good thing I was out there already. LOL! :D

RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

hello HappyBoomerNurse :) glad you enjyed my seminar :) please show you RN license at the door to receive your virtual CEU's :) I thought your hub on Dr Burzynski was fatastic and am looking for it to rent!

oh travel_man1971 so THAT was YOU I was chasing with my DULL 14 gauge 2 and 1/2 inch needle and syringe!!!!!!!

:) no really you are absolutely correct so many things for a nurse to try and keep a grip on/not easy dude! But we love it!!

You're lucky Kratchet never caught you, they'd never have found your body parts...well not ALL of them anyway hahahaha

Happyboomernurse profile image

Happyboomernurse 5 years ago from South Carolina

A FREE showing of Burzynski: The Movie is available until June 20, 2011 (ends 11:59 PM) at the following website:

RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

ooohh hey you guys only 24 hours left!!! take advantage of this!! thank you HappyBoomerNurse :)

kimh039 profile image

kimh039 5 years ago

very interesting, RNMSN. I answered #2 so you could be my supervisor. That doesn't seem like it would be so horrible. Being a trainee generally sucks for awhile though. Do I need a nursing license?

RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

oh Kim you can work for and with me anytime!!! but yes, unfortunately they do not allow apprenticeship for nursing dadgumit!

much love to you

barbara b

Pharme241 3 years ago

Very nice site!

holyjeans30 profile image

holyjeans30 2 years ago from Mostly in My Own Little World

Great post. You're absolutely right, they do "sear" those 5 rules in your brain. I don't know how many times I witnessed medication errors, and a lot of times (not all) but a lot of times it was new nurses who were still getting the hang of things. I don't necessarily think there should be more or less as far as the number of rules or checks, as much as I feel like it should be mandatory to have to check, double, and even triple check, and on some occasions have a second nurse there to help check, especially with the more dangerous medications. I know that's really unreasonable though. Individuals just have to make it a point on their own to make sure they check the "5Rs". I've seen a lot of bad things happen with med errors from babies to elderly.

RNMSN profile image

RNMSN 2 years ago from Tucson, Az Author

thank you holyjeans! always a good idea to get another set of eyes if possible I agree but in this very busy world that can be a luxury we cannot afford/so just keep doing great things !

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