Why Neither the “Five Rights” Nor Bar Code Medication Administration Alone Will Prevent Medication Errors

Medication administration is one of the most error-prone processes in health care delivery. The “five rights” are regarded as a basic goal for safe medication administration: right patient, right medication, right time, right dose, and right route. Many errors, including lethal errors, still occur when practitioners firmly believe that they have verified the five rights before administering a medication. How can this happen?


How do we decide what to put in our patient safety evaluation system (PSES)?
—S.G., a hospital in southern California

A patient safety evaluation system is the system you use to collect, manage, and analyze information (patient safety work product) for reporting to your patient safety organization, CHPSO. There is no one-size-fits-all policy; each health care facility has needs that others may not experience. It is important to keep in mind that the PSES can be an evolutionary document and it is beneficial to revisit it regularly. While most hospitals submit all incident reports and RCAs to CHPSO, some may only report specific event categories.


When Doctors and Patients Turn to Their Phones for Health Care

With nearly 100,000 health related apps available at the fingertips of smartphone or tablet users, consumers can capture their vitals without having to step into a hospital. Mobile health, or mHealth, involves using these smartphones or tablets for a medical purpose. Software applications, or apps, can provide diabetes management, track sleeping habits, and screen for depression.


Multi-Dose Vials: Reminder

If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use. Examples of the immediate patient treatment area include patient rooms or bays, and operating rooms.


Case Synopses for this Issue

Case reports received by CHPSO provided the lessons learned for this issue. Following are brief examples. Details may have been changed to protect patient and provider confidentiality.