Examining the Adequacy of the 5 Rights of Medication Administration
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
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 participation in care will be presented. A path forward is offered based on the expressivecollaborative 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 patientcentered 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 involved in the process share the responsibility for a safe medication use system.
P
KEY WORDS: expressive-collaborative model, medication 5 rights, patient centered
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
P
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 monitor medications can potentially lead to adverse events and
harm. For decades, nurses have practiced the 5 rights (5 R’s)
of medication administration6: right patient, right drug,
right dose, right route, and right time, as a process to minimize risk of error in medication administration. The 5 R’s of
medication administration were developed for use by nurses,
and consequently, the role of the patient in the medication
administration process has only recently been considered.
Increasingly, hospitalized patients want to play a greater
role in their treatment and care and see a role for themselves
in medication administration.7 The purpose of this article
was to examine the adequacy of the 5 R’s for nurses and for
including patients in medication administration while considering patient safety. Patient safety related to medication
adverse events is discussed. The 5 R’s are examined and
critiqued. The importance of patient-centered care and patient
participation in care is presented, and a path forward is
offered based on the expressive-collaborative model of ethical
reasoning. Finally, suggestions on the introduction of the
model are offered, and implications for practice, research,
and education are discussed.
PATIENT SAFETY AND MEDICATIONS
Compromised safety in medication management can be
extremely costly to patients, health care professionals, and
the health care system.5,8,9–11 A recent report on medication
safety concluded that approximately 1.5 million preventable
adverse drug events occur per year, resulting in a total cost
of US $3.5 billion.12 Similarly, as many as 1 in 5 Canadian
patients admitted to the hospital experienced adverse events
at the point of discharge home, and 66% of these were
medication-related events.13–15 Medication-related events
are estimated to cost Canadians $750 million.16 A study of
Halifax, Nova Scotia, seniors found that as many as 1 in
11 experienced a preventable drug-related morbidity over a
2-year period.17 Moreover, patients also recognize problems
with the manner in which medications are provided to them.
In the 2003 Commonwealth Fund Survey, 11% of patients
in Canada reported that they had been given the wrong
medication at one time or another.18
CRITIQUE OF THE 5 R’S
Nurses administer the majority of medications in hospitals.
The standard most frequently referred to guide the medication administration process is that of the 5 R’s as described above. Following the 5 R’s implies that a medication
error will not occur. However, clinicians, researchers, and
administrators realize that adherence to the 5 R’s is not a
stand alone process. Furthermore, a considerable volume of
literature exists on the inadequacy of relying on the 5 R’s.
Most medication errors occur at the points of ordering
(39%) and administering medications (38%).19
The 5 R’s were established in an era when the paradigm
guiding care delivery held individuals solely responsible in
the event of any type of error in care delivery. The context in
which care was delivered remained unexamined. Gradually,
clinicians and researchers came to recognize that this culture of blame did little to address the occurrence of errors
and in fact resulted in a failure to report errors and, as
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a result, a failure to learn and to understand the cause of
many errors.20
The limitations surrounding sole reliance on the 5 R’s for
medication administration have been recognized for some
time, and efforts have proceeded to augment the 5 R’s in
2 ways: first, by adding additional rights and, second, by
proposing rights for the nurse administering the medications.
Suggestions that have been made in terms of augmenting the
5 R’s include right indication, right documentation,21 and
right equipment.22 Cook23 proposed a series of rights for
nurses that included the right to have legible orders, correct
drug dispensing, timely access to information, procedures in
place to support medication administration, the time it takes
to safely administer medications, and problems addressed in
the medication administration system.
Work interruptions during medication administration are
also known to be a source of medication errors. The number
of interruptions is estimated to be 6.7 per hour.24 A recent
review of the literature on interruptions revealed that a more
precise definition of interruptions is necessary and that nurses
themselves initiated most of the interruptions.24 Clearly, interruptions 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
the inadequacy of simply adding rights to the existing process. The Institute for Safe Medication Practices points out
that verifying a patient armband does not guarantee that the
armband belongs to the person wearing it and that the
medication in the bubble pack is what is written on the label.
The lesson in this work is that medication administration is
part of a complex system of care delivery and that all aspects
of the system must be functioning properly to minimize the
chance of error during the delivery of patient care.
Nurses themselves realize that the medication administration process is much more than the 5 R’s. The 5 R’s are
initiated at the point of medication administration; however,
a host of actions occurs well before this step including
checking medication orders, following up with pharmacy on
missing medications, and assessing the patient.26 The literature makes it abundantly clear that the process of medication administration is a complex one, one in which all
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 administration process is to safely administer medications to patients.
Despite this, there is a lack of consideration of the role of the
patient in these processes. Not only has the manner of looking at medication errors shifted from individuals to systems,
but also the care provider is no longer seen as solely responsible for the well-being of the patient.
PATIENT-CENTERED CARE
Patients are not passive recipients of health care. In 1998,
the Canadian Institute for Health Information spearheaded
a consultation process to determine patient health information needs. Consumers were included in this consultation,
and one of the priorities advanced from this initiative was
the distribution of health information to consumers (www.
cihi.ca).27 Knowing this, the Canadian Patient Safety
Institute has included the involvement of patients as a
priority area for research.2 One of the priorities identified by
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197
Canadian Patient Safety Institute related to patients is the
patient role in safety.
In 2002, citizens from the United States formed the Consumers Advancing Patient Safety.28 This organization consisted of patients’ family members who had experienced loss
as a result of adverse events. Today, this organization exists
to provide consumers a voice regarding health care safety
and the ability to serve as a resource for care delivery centers to become more patient centered (www.patientsafety.
org).
Within the Canadian context, a 2002 survey of patient
views on the patient-provider relationship found that more
than 50% of patients believe they have the primary responsibility for decisions regarding their health. An additional 35.6% expect decision making to be shared between
themselves and their health care provider.29
Canadian patients seek and expect to receive information
regarding their health condition.30 Because safety is an integral part of health care, involving patients in issues related
to their own safety presents as one means of reorganizing
services so that the power to provide safe health care is
shared. In support of this statement, the World Health
Organization World Alliance for Patient Safety launched an
initiative in 2004 to coordinate global and national efforts
to improve patient safety. The World Health Organization
World Alliance for Patient Safety stressed that patient,
family, and citizen perspectives must be central to patient
safety.31 Most regional, national, and international conference programs now include testimonials from patients and
families about individual adverse events.
Further evidence of a shift in thinking from provider-only
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
robust documents are briefly described here to illustrate this
shift in thinking. They are the (1) Registered Nurses of
Ontario’s32 Best Practice Guideline on Patient-Centered
Care; (2) American College of Critical Care Medicine’s33
Clinical Practice Guideline for Patient-Centered Intensive
Care Units; and (3) Picker Institute and Commonwealth
Fund–sponsored report on patient-centered care.34
Many health care delivery centers describe the care they
provide as patient centered. Patient-centered care encompasses respect for human dignity, the belief that patients are
experts of their own lives, and respect for patient goals. Patient care based on values of continuity, consistency, timeliness, responsiveness, and universal access will also be safe
care (Registered Nurses of Ontario).32 Asking patients and
families about what they want and how they see their health
care is part of patient-centered care.
The American College of Critical Care Medicine’s Clinical Practice Guideline outlined how providers need to act in
relation to patients and families in all aspects of their care.
This guideline strongly supports including patient and
family perspectives and the inclusion of patients and families
in the decision-making process.
The Picker Institute and Commonwealth Fund report on
patient-centered care outlined the attributes expected in a
patient care environment, one of which is the involvement of
patients and families. The author explained that this involvement must be provided at multiple levels from the bedside to
developing policy. What is absent from these important
198
documents is the elaboration of the factors that silence the
patient voice and how to banish the silence.
Partnering with patients to conduct research about
patient safety is congruent with a patient-centered philosophy and with the tenets of primary health care and health
promotion outlined in the Ottawa Charter.35 Central to the
Charter is the message that health systems must reorganize
in such a way as to ‘‘share power with other sectors, other
disciplines and most importantly with people themselves’’(p427)
and that health is not the sole responsibility of the health
care provider and the health care system. Recently, in a
study on the perspectives of patients and nurses on the role
of the patient in medication administration safety,7 participants confirmed that they saw a role for patients in medication administration even if the role was limited to the
patient (who is able) verifying with the nurse that the medications about to be ingested were in fact what they usually
take.
A medication reconciliation safety initiative is under
way across North America. This initiative involves the
verification of a patient’s medications upon admission or at
triage in an emergency department and at every care
transfer point. This initiative is a good example of a
strategy to engage patients in their care. The only way that
reconciliation will work is if the initial medication history is
accurate,36 and this means the person interviewing the
patient must minimize the provider-patient authority
gradient so that patients sense that they are trusted and
respected. This trust and respect enable patients to be
forthcoming about what medications they really do take,
how much, and how often.
INCONGRUENCE BETWEEN 5 R’s AND
PATIENT-CENTERED CARE
The 5 R’s were introduced to the medication administration
process at a time when the health care provider was deemed
the expert in illness and treatment related matters. Learning
about medication administration following the 5 R’s is no
longer adequate. Nurses take the medication administration
process much further than simply following the 5 R’s.
Nurses have identified the importance of teaching patients
about their medications and the need for patient involvement in the medication administration process when
possible.7 Nurses collaborate with physicians and pharmacists on an ongoing basis regarding medications. Many
patients want to be more involved in the decision making
around their medications as well as all aspects of care.
Nurses, physicians, and pharmacists have an opportunity to
explore with patients, approaches to medication administration that incorporate a systems approach, and interprofessional patient-centered medication administration. A variety
of theories were considered to guide such an initiative, and
a theory based in ethics was selected for its relevance to all
involved.
FROM 5 R’s TO PATIENT CENTEREDNESS
Traditional ethical models such as the theoretical judicial
model37 of thinking predominated throughout much of the
20th century. Our society is stratified by sex, class, race, age,
CLINICAL NURSE SPECIALISTA
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
education, and many other layers of power and status. Because of these layers, members with health and medical
backgrounds perceive situations differently from those without a health care background. According to the theoretical
judicial model, those with power and status were considered
to be all knowing and decided what was best for all involved, in this case, health care. In the past, the views of
patients and families were largely discounted, as well as
the context of their lives, in decisions regarding care and
medication administration.
The major challenge to model implementation identified
was the engagement of all involved, to trust in the process
and to be willing to keep working at the process to get it
right. This means entry into a process of creation of a different way of being and doing. This process is not efficient
in the short term, and this is particularly challenging for
individuals who seek early results.
EXPRESSIVE-COLLABORATIVE MODEL
The skills necessary for incorporating this model into clinical nurse specialist (CNS) practice involve perception,
discussion, and responding, all of which the CNS role embraces. Practicing within the model necessitates an ability to
respond sensitively in feeling and behavior, an ability to
clearly describe and explain activities and situations, an
appreciation that each person has a level of knowledge and
understanding, and the ability to establish some basis of
moral equilibrium with patients. The model represents a
way of thinking about how we (nurses) are in relation to
patients; if we believe that we know best, then disequilibrium results and the likelihood of patient participation in
any aspect of their care is reduced.
The CNS is constantly consulted in situations that prove
to be clinically and interpersonally challenging and is ideally
suited to identifying situations in which the moral wishes of
the patient have not been respected. This model offers the
CNS a way forward in these situations. The challenges to
CNS practice in embracing the model are to recognize that
many of the health care providers they work with may be
holding firmly to the theoretical judicial model. Engaging
everyone involved in a collaborative process means bringing
together individuals with dissenting points of view and facilitating a group process that seeks balance over compliance necessitating skills in handling conflict and discord.
The CNS as facilitator also needs to be a reflective practitioner and to guard against unduly influencing the process
because of a particular personally desired outcome.
An ethical model that embraces patient-centered care is the
expressive-collaborative model.37 This model is a philosophical model that takes a moral view of life, with a particular
focus on sharing responsibility among human beings. The
skills necessary to enact the model are perception, discussion,
and ability to respond. This model invites individuals to examine the moral view of life that we hold and to what extent
we expect patients to act in a particular way, and how patients are judged if they fail to do so. Moral equilibrium is the
goal, related to beliefs, perceptions, expressions, judgments,
actions, and responses. Tolerance will not do; ultimately,
mutual respect is desired via a consensual process. Patients
need to be considered as full moral agents, and traditional
moral understandings such as the complete authority of providers over medication administration are questioned.
This model advances that all human beings carry moral
identities shaped by the lives we have lived, and these identities are imbued with moral judgments. These judgments may
extend to how we believe the patients we care for should
look, act, be, and do. The model encourages us to examine
the moral view of responsibility that we hold, to reflect on
the extent to which we expect patients to act in a particular
way, and to recognize provider tendencies to locate failure in
patients forgetting there is a level of shared responsibility.
Patients need to be considered as full moral agents; traditional practices such as health care providers having complete control over medication administration are questioned.
Moral order is necessary and always present. It is the disequilibrium in the order that the model seeks to address. In this
model, individuals negotiate with one another to find out
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
fit all; rather, each person is considered to have a level of
knowledge and understanding that is valued, and health professionals will tap into this and work with the person collaboratively to determine how a course of treatment is to unfold.
Application of the model was not found in the nursing
and health-related literature but rather in the education literature,38 where the administrative and educational challenges
as well as the strategies for implementation were discussed.
A central administrative challenge was the existence of the
theoretical judicial model and the enactment of a certain
‘‘moral’’ order in schools. Educators and administrators spent
significant amounts of time determining a code of conduct
for students. Introducing the expressive-collaborative model
necessitated broad consultation with all involved, increasing
the likelihood of students self-managing the agreed-on behaviors and leaving administrators and educators time for
doing direct administrative and educational activities.
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EXPRESSIVE-COLLABORATIVE MODEL AND
CLINICAL NURSE SPECIALIST PRACTICE
INTRODUCING THE
EXPRESSIVE-COLLABORATIVE MODEL
This model has the potential to frame the way entire healthrelated organizations operate. Organization-wide implementation all at once is not recommended because the model is a
process of creation and as such needs to happen in one
setting at a time. The CNS is ideally suited as the individual
to introduce use of the model one situation at a time, and as
those involved experience the process, a change in thinking
and approach will begin to occur one person at a time. Once
the model has been successfully used in a variety of situations and settings and those involved believe in the process,
then consideration can be given to wider implementation of
the model in other settings.
EXPRESSIVE-COLLABORATIVE MODEL, 5 R’s,
AND SAFETY
One can see how the establishment of the 5 R’s for nurses
to administer medications made sense in the era of the
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199
theoretical judicial model. Medication administration was
seen as a single act performed by a nurse and not as part of
a larger system. Today, we know that the main players in
medication administration (physician, nurse, pharmacist,
patient) are intricately interconnected; each has a stake in
making sure that the medication administration system
functions effectively. This will require each player respectively and collaboratively identify and articulate the processes necessary to ensure system integrity, and each player
needs to know and understand the processes of all players.
Patients are the newest players in this process and as such
will need considerable mentoring by those familiar with
medication use systems. The health care provider team and
the patient will ultimately formulate what the next iteration
of the 5 R’s will be; however, small examples of revisions to
existing processes may include requiring patients where
appropriate to identify the medications they are about to
take and the indications for the medications. Pharmacy may
consider issuing where appropriate a medication administration record to the patient for their reference and to
promote patient self-management of medications.
The challenge is shared by all involved in medication
management, and it is 2-fold: first to collaboratively restructure the medication use processes to reflect what each
person in the process is required to do and, second, to
recognize that patients are partners as, they have knowledge
and expertise, and they are why we are here. By taking up
this challenge, we will move from the era of the 5 R’s for
one player to the era of collaborative patient-centered practice wherein consensus is reached among all involved in
medication use on the elements necessary for each player
to enact to safely participate in the medication administration process.
IMPLICATIONS FOR PRACTICE, RESEARCH,
AND EDUCATION
The 5 R’s have served to frame the medication administration process in a time when providers of care were
considered all knowing. The expressive-collaborative model
advances the notion that the knowledge of everyone
involved in health-related processes is legitimate and valued
and needs to be integrated into care processes. The 5 R’s
will need to evolve in a manner that embraces collaborative
practice. The CNS is ideally situated to facilitate the process
of bringing together the key players in medication administration to revise the 5 R’s so that they reflect the collective
knowledge and responsibilities of all involved. The revised
process will need to be pilot tested and evaluated. If further
refinement is necessary, those who developed the process
will reconvene.
Once the revised process is deemed operational, the
process will be implemented, first within one setting and
then gradually expanded. Health care centers already monitor medication-related errors, and this process will reveal
any new trends. Research studies will need to be designed to
determine the satisfaction of those involved in the process,
as well as the benefits and challenges in the process.
Following successful development, implementation, and
evaluation of the revised medication administration process,
education will be required for all involved. This education
200
will also need to be introduced into programs for nursing
education.
CONCLUSIONS
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 systems in this era in
which all involved in the process understand respective roles
and share the responsibility for a safe medication use
system. The proposed revision to the medication administration process is not simply adding a step or two to an
existing process, but rather, a rethinking of attitudes and
actions on the part of each person involved in the medication use system. The hope is that, by each participating
person, viewing the medication administration process in a
new way that gains can be made in making the process more
responsive and safer for all involved.
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201
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
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 participation in care will be presented. A path forward is offered based on the expressivecollaborative 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 patientcentered 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 involved in the process share the responsibility for a safe medication use system.
P
KEY WORDS: expressive-collaborative model, medication 5 rights, patient centered
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
P
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 monitor medications can potentially lead to adverse events and
harm. For decades, nurses have practiced the 5 rights (5 R’s)
of medication administration6: right patient, right drug,
right dose, right route, and right time, as a process to minimize risk of error in medication administration. The 5 R’s of
medication administration were developed for use by nurses,
and consequently, the role of the patient in the medication
administration process has only recently been considered.
Increasingly, hospitalized patients want to play a greater
role in their treatment and care and see a role for themselves
in medication administration.7 The purpose of this article
was to examine the adequacy of the 5 R’s for nurses and for
including patients in medication administration while considering patient safety. Patient safety related to medication
adverse events is discussed. The 5 R’s are examined and
critiqued. The importance of patient-centered care and patient
participation in care is presented, and a path forward is
offered based on the expressive-collaborative model of ethical
reasoning. Finally, suggestions on the introduction of the
model are offered, and implications for practice, research,
and education are discussed.
PATIENT SAFETY AND MEDICATIONS
Compromised safety in medication management can be
extremely costly to patients, health care professionals, and
the health care system.5,8,9–11 A recent report on medication
safety concluded that approximately 1.5 million preventable
adverse drug events occur per year, resulting in a total cost
of US $3.5 billion.12 Similarly, as many as 1 in 5 Canadian
patients admitted to the hospital experienced adverse events
at the point of discharge home, and 66% of these were
medication-related events.13–15 Medication-related events
are estimated to cost Canadians $750 million.16 A study of
Halifax, Nova Scotia, seniors found that as many as 1 in
11 experienced a preventable drug-related morbidity over a
2-year period.17 Moreover, patients also recognize problems
with the manner in which medications are provided to them.
In the 2003 Commonwealth Fund Survey, 11% of patients
in Canada reported that they had been given the wrong
medication at one time or another.18
CRITIQUE OF THE 5 R’S
Nurses administer the majority of medications in hospitals.
The standard most frequently referred to guide the medication administration process is that of the 5 R’s as described above. Following the 5 R’s implies that a medication
error will not occur. However, clinicians, researchers, and
administrators realize that adherence to the 5 R’s is not a
stand alone process. Furthermore, a considerable volume of
literature exists on the inadequacy of relying on the 5 R’s.
Most medication errors occur at the points of ordering
(39%) and administering medications (38%).19
The 5 R’s were established in an era when the paradigm
guiding care delivery held individuals solely responsible in
the event of any type of error in care delivery. The context in
which care was delivered remained unexamined. Gradually,
clinicians and researchers came to recognize that this culture of blame did little to address the occurrence of errors
and in fact resulted in a failure to report errors and, as
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a result, a failure to learn and to understand the cause of
many errors.20
The limitations surrounding sole reliance on the 5 R’s for
medication administration have been recognized for some
time, and efforts have proceeded to augment the 5 R’s in
2 ways: first, by adding additional rights and, second, by
proposing rights for the nurse administering the medications.
Suggestions that have been made in terms of augmenting the
5 R’s include right indication, right documentation,21 and
right equipment.22 Cook23 proposed a series of rights for
nurses that included the right to have legible orders, correct
drug dispensing, timely access to information, procedures in
place to support medication administration, the time it takes
to safely administer medications, and problems addressed in
the medication administration system.
Work interruptions during medication administration are
also known to be a source of medication errors. The number
of interruptions is estimated to be 6.7 per hour.24 A recent
review of the literature on interruptions revealed that a more
precise definition of interruptions is necessary and that nurses
themselves initiated most of the interruptions.24 Clearly, interruptions 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
the inadequacy of simply adding rights to the existing process. The Institute for Safe Medication Practices points out
that verifying a patient armband does not guarantee that the
armband belongs to the person wearing it and that the
medication in the bubble pack is what is written on the label.
The lesson in this work is that medication administration is
part of a complex system of care delivery and that all aspects
of the system must be functioning properly to minimize the
chance of error during the delivery of patient care.
Nurses themselves realize that the medication administration process is much more than the 5 R’s. The 5 R’s are
initiated at the point of medication administration; however,
a host of actions occurs well before this step including
checking medication orders, following up with pharmacy on
missing medications, and assessing the patient.26 The literature makes it abundantly clear that the process of medication administration is a complex one, one in which all
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 administration process is to safely administer medications to patients.
Despite this, there is a lack of consideration of the role of the
patient in these processes. Not only has the manner of looking at medication errors shifted from individuals to systems,
but also the care provider is no longer seen as solely responsible for the well-being of the patient.
PATIENT-CENTERED CARE
Patients are not passive recipients of health care. In 1998,
the Canadian Institute for Health Information spearheaded
a consultation process to determine patient health information needs. Consumers were included in this consultation,
and one of the priorities advanced from this initiative was
the distribution of health information to consumers (www.
cihi.ca).27 Knowing this, the Canadian Patient Safety
Institute has included the involvement of patients as a
priority area for research.2 One of the priorities identified by
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197
Canadian Patient Safety Institute related to patients is the
patient role in safety.
In 2002, citizens from the United States formed the Consumers Advancing Patient Safety.28 This organization consisted of patients’ family members who had experienced loss
as a result of adverse events. Today, this organization exists
to provide consumers a voice regarding health care safety
and the ability to serve as a resource for care delivery centers to become more patient centered (www.patientsafety.
org).
Within the Canadian context, a 2002 survey of patient
views on the patient-provider relationship found that more
than 50% of patients believe they have the primary responsibility for decisions regarding their health. An additional 35.6% expect decision making to be shared between
themselves and their health care provider.29
Canadian patients seek and expect to receive information
regarding their health condition.30 Because safety is an integral part of health care, involving patients in issues related
to their own safety presents as one means of reorganizing
services so that the power to provide safe health care is
shared. In support of this statement, the World Health
Organization World Alliance for Patient Safety launched an
initiative in 2004 to coordinate global and national efforts
to improve patient safety. The World Health Organization
World Alliance for Patient Safety stressed that patient,
family, and citizen perspectives must be central to patient
safety.31 Most regional, national, and international conference programs now include testimonials from patients and
families about individual adverse events.
Further evidence of a shift in thinking from provider-only
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
robust documents are briefly described here to illustrate this
shift in thinking. They are the (1) Registered Nurses of
Ontario’s32 Best Practice Guideline on Patient-Centered
Care; (2) American College of Critical Care Medicine’s33
Clinical Practice Guideline for Patient-Centered Intensive
Care Units; and (3) Picker Institute and Commonwealth
Fund–sponsored report on patient-centered care.34
Many health care delivery centers describe the care they
provide as patient centered. Patient-centered care encompasses respect for human dignity, the belief that patients are
experts of their own lives, and respect for patient goals. Patient care based on values of continuity, consistency, timeliness, responsiveness, and universal access will also be safe
care (Registered Nurses of Ontario).32 Asking patients and
families about what they want and how they see their health
care is part of patient-centered care.
The American College of Critical Care Medicine’s Clinical Practice Guideline outlined how providers need to act in
relation to patients and families in all aspects of their care.
This guideline strongly supports including patient and
family perspectives and the inclusion of patients and families
in the decision-making process.
The Picker Institute and Commonwealth Fund report on
patient-centered care outlined the attributes expected in a
patient care environment, one of which is the involvement of
patients and families. The author explained that this involvement must be provided at multiple levels from the bedside to
developing policy. What is absent from these important
198
documents is the elaboration of the factors that silence the
patient voice and how to banish the silence.
Partnering with patients to conduct research about
patient safety is congruent with a patient-centered philosophy and with the tenets of primary health care and health
promotion outlined in the Ottawa Charter.35 Central to the
Charter is the message that health systems must reorganize
in such a way as to ‘‘share power with other sectors, other
disciplines and most importantly with people themselves’’(p427)
and that health is not the sole responsibility of the health
care provider and the health care system. Recently, in a
study on the perspectives of patients and nurses on the role
of the patient in medication administration safety,7 participants confirmed that they saw a role for patients in medication administration even if the role was limited to the
patient (who is able) verifying with the nurse that the medications about to be ingested were in fact what they usually
take.
A medication reconciliation safety initiative is under
way across North America. This initiative involves the
verification of a patient’s medications upon admission or at
triage in an emergency department and at every care
transfer point. This initiative is a good example of a
strategy to engage patients in their care. The only way that
reconciliation will work is if the initial medication history is
accurate,36 and this means the person interviewing the
patient must minimize the provider-patient authority
gradient so that patients sense that they are trusted and
respected. This trust and respect enable patients to be
forthcoming about what medications they really do take,
how much, and how often.
INCONGRUENCE BETWEEN 5 R’s AND
PATIENT-CENTERED CARE
The 5 R’s were introduced to the medication administration
process at a time when the health care provider was deemed
the expert in illness and treatment related matters. Learning
about medication administration following the 5 R’s is no
longer adequate. Nurses take the medication administration
process much further than simply following the 5 R’s.
Nurses have identified the importance of teaching patients
about their medications and the need for patient involvement in the medication administration process when
possible.7 Nurses collaborate with physicians and pharmacists on an ongoing basis regarding medications. Many
patients want to be more involved in the decision making
around their medications as well as all aspects of care.
Nurses, physicians, and pharmacists have an opportunity to
explore with patients, approaches to medication administration that incorporate a systems approach, and interprofessional patient-centered medication administration. A variety
of theories were considered to guide such an initiative, and
a theory based in ethics was selected for its relevance to all
involved.
FROM 5 R’s TO PATIENT CENTEREDNESS
Traditional ethical models such as the theoretical judicial
model37 of thinking predominated throughout much of the
20th century. Our society is stratified by sex, class, race, age,
CLINICAL NURSE SPECIALISTA
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
education, and many other layers of power and status. Because of these layers, members with health and medical
backgrounds perceive situations differently from those without a health care background. According to the theoretical
judicial model, those with power and status were considered
to be all knowing and decided what was best for all involved, in this case, health care. In the past, the views of
patients and families were largely discounted, as well as
the context of their lives, in decisions regarding care and
medication administration.
The major challenge to model implementation identified
was the engagement of all involved, to trust in the process
and to be willing to keep working at the process to get it
right. This means entry into a process of creation of a different way of being and doing. This process is not efficient
in the short term, and this is particularly challenging for
individuals who seek early results.
EXPRESSIVE-COLLABORATIVE MODEL
The skills necessary for incorporating this model into clinical nurse specialist (CNS) practice involve perception,
discussion, and responding, all of which the CNS role embraces. Practicing within the model necessitates an ability to
respond sensitively in feeling and behavior, an ability to
clearly describe and explain activities and situations, an
appreciation that each person has a level of knowledge and
understanding, and the ability to establish some basis of
moral equilibrium with patients. The model represents a
way of thinking about how we (nurses) are in relation to
patients; if we believe that we know best, then disequilibrium results and the likelihood of patient participation in
any aspect of their care is reduced.
The CNS is constantly consulted in situations that prove
to be clinically and interpersonally challenging and is ideally
suited to identifying situations in which the moral wishes of
the patient have not been respected. This model offers the
CNS a way forward in these situations. The challenges to
CNS practice in embracing the model are to recognize that
many of the health care providers they work with may be
holding firmly to the theoretical judicial model. Engaging
everyone involved in a collaborative process means bringing
together individuals with dissenting points of view and facilitating a group process that seeks balance over compliance necessitating skills in handling conflict and discord.
The CNS as facilitator also needs to be a reflective practitioner and to guard against unduly influencing the process
because of a particular personally desired outcome.
An ethical model that embraces patient-centered care is the
expressive-collaborative model.37 This model is a philosophical model that takes a moral view of life, with a particular
focus on sharing responsibility among human beings. The
skills necessary to enact the model are perception, discussion,
and ability to respond. This model invites individuals to examine the moral view of life that we hold and to what extent
we expect patients to act in a particular way, and how patients are judged if they fail to do so. Moral equilibrium is the
goal, related to beliefs, perceptions, expressions, judgments,
actions, and responses. Tolerance will not do; ultimately,
mutual respect is desired via a consensual process. Patients
need to be considered as full moral agents, and traditional
moral understandings such as the complete authority of providers over medication administration are questioned.
This model advances that all human beings carry moral
identities shaped by the lives we have lived, and these identities are imbued with moral judgments. These judgments may
extend to how we believe the patients we care for should
look, act, be, and do. The model encourages us to examine
the moral view of responsibility that we hold, to reflect on
the extent to which we expect patients to act in a particular
way, and to recognize provider tendencies to locate failure in
patients forgetting there is a level of shared responsibility.
Patients need to be considered as full moral agents; traditional practices such as health care providers having complete control over medication administration are questioned.
Moral order is necessary and always present. It is the disequilibrium in the order that the model seeks to address. In this
model, individuals negotiate with one another to find out
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
fit all; rather, each person is considered to have a level of
knowledge and understanding that is valued, and health professionals will tap into this and work with the person collaboratively to determine how a course of treatment is to unfold.
Application of the model was not found in the nursing
and health-related literature but rather in the education literature,38 where the administrative and educational challenges
as well as the strategies for implementation were discussed.
A central administrative challenge was the existence of the
theoretical judicial model and the enactment of a certain
‘‘moral’’ order in schools. Educators and administrators spent
significant amounts of time determining a code of conduct
for students. Introducing the expressive-collaborative model
necessitated broad consultation with all involved, increasing
the likelihood of students self-managing the agreed-on behaviors and leaving administrators and educators time for
doing direct administrative and educational activities.
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EXPRESSIVE-COLLABORATIVE MODEL AND
CLINICAL NURSE SPECIALIST PRACTICE
INTRODUCING THE
EXPRESSIVE-COLLABORATIVE MODEL
This model has the potential to frame the way entire healthrelated organizations operate. Organization-wide implementation all at once is not recommended because the model is a
process of creation and as such needs to happen in one
setting at a time. The CNS is ideally suited as the individual
to introduce use of the model one situation at a time, and as
those involved experience the process, a change in thinking
and approach will begin to occur one person at a time. Once
the model has been successfully used in a variety of situations and settings and those involved believe in the process,
then consideration can be given to wider implementation of
the model in other settings.
EXPRESSIVE-COLLABORATIVE MODEL, 5 R’s,
AND SAFETY
One can see how the establishment of the 5 R’s for nurses
to administer medications made sense in the era of the
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199
theoretical judicial model. Medication administration was
seen as a single act performed by a nurse and not as part of
a larger system. Today, we know that the main players in
medication administration (physician, nurse, pharmacist,
patient) are intricately interconnected; each has a stake in
making sure that the medication administration system
functions effectively. This will require each player respectively and collaboratively identify and articulate the processes necessary to ensure system integrity, and each player
needs to know and understand the processes of all players.
Patients are the newest players in this process and as such
will need considerable mentoring by those familiar with
medication use systems. The health care provider team and
the patient will ultimately formulate what the next iteration
of the 5 R’s will be; however, small examples of revisions to
existing processes may include requiring patients where
appropriate to identify the medications they are about to
take and the indications for the medications. Pharmacy may
consider issuing where appropriate a medication administration record to the patient for their reference and to
promote patient self-management of medications.
The challenge is shared by all involved in medication
management, and it is 2-fold: first to collaboratively restructure the medication use processes to reflect what each
person in the process is required to do and, second, to
recognize that patients are partners as, they have knowledge
and expertise, and they are why we are here. By taking up
this challenge, we will move from the era of the 5 R’s for
one player to the era of collaborative patient-centered practice wherein consensus is reached among all involved in
medication use on the elements necessary for each player
to enact to safely participate in the medication administration process.
IMPLICATIONS FOR PRACTICE, RESEARCH,
AND EDUCATION
The 5 R’s have served to frame the medication administration process in a time when providers of care were
considered all knowing. The expressive-collaborative model
advances the notion that the knowledge of everyone
involved in health-related processes is legitimate and valued
and needs to be integrated into care processes. The 5 R’s
will need to evolve in a manner that embraces collaborative
practice. The CNS is ideally situated to facilitate the process
of bringing together the key players in medication administration to revise the 5 R’s so that they reflect the collective
knowledge and responsibilities of all involved. The revised
process will need to be pilot tested and evaluated. If further
refinement is necessary, those who developed the process
will reconvene.
Once the revised process is deemed operational, the
process will be implemented, first within one setting and
then gradually expanded. Health care centers already monitor medication-related errors, and this process will reveal
any new trends. Research studies will need to be designed to
determine the satisfaction of those involved in the process,
as well as the benefits and challenges in the process.
Following successful development, implementation, and
evaluation of the revised medication administration process,
education will be required for all involved. This education
200
will also need to be introduced into programs for nursing
education.
CONCLUSIONS
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 systems in this era in
which all involved in the process understand respective roles
and share the responsibility for a safe medication use
system. The proposed revision to the medication administration process is not simply adding a step or two to an
existing process, but rather, a rethinking of attitudes and
actions on the part of each person involved in the medication use system. The hope is that, by each participating
person, viewing the medication administration process in a
new way that gains can be made in making the process more
responsive and safer for all involved.
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