The "five rights" of medication administration has long been a guide for nurses on the keys to medication safety. Administering the right drug to the right patient in the right dose by the right route at the right time makes it seem as though the process should be simple.
However, in the real world of the hospital and other healthcare settings, everyone knows the situation is more complicated. In recent years the five rights have grown to seven, eight, nine and even twelve rights for medication administration, adding extras like right documentation, right reason, right to refuse, right response and others.
The ISMP and others like the Pennsylvania Patient Safety Authority have long argued that the five rights are inherently flawed because they assume that medication errors are solely based on the human error of the administrating caregiver. Piling on more and more rights doesn’t help, and won’t make medication errors disappear.
Often with medication errors you have to look beyond the point of administration to find the root cause of the issue. System issues and confirmation bias can blind you to a true system or process problem. It’s here where the "5 Whys" can come in handy.
The 5 Whys is a simple tool originally made popular by Toyota Production System to identify root causes quickly. First you clearly state the problem, then ask why that problem happened and write down the answer.
Continue asking why to the previous answer until the problem’s root cause has been identified. It may also be useful to use process mapping or visualize the process to narrow down the most likely sources for the problem. Download our free webinar on the 5 Whys.
Using the 5 Whys is just one of the ways that LEAN practices can be applied to the medication use process. Our Pharmtrac.PD medication tracking software was developed by experts in pharmacy operations and Lean Six Sigma. We’d love to hear about what problems you are facing in your pharmacy and help brainstorm some solutions. Contact us today to find out how we can help improve your hospital’s existing processes.
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