In a just and high safety culture, failures are looked at in a systems approach rather than via the blame the individual approach. In a resilient organization that is consistently monitoring its failures and potential for failures, the most likely statement would be: There was a medication error in the PACU. The processes that led to the failure would be reviewed and a prevention plan would be developed with the assistance of the nurse who was at the sharp end of the failure.
The statement about the 5 rights is not likely to be heard as this also implies only individual accountability. For more information about weaknesses in reliance on the 5 rights framework, read this from the ISMP:
Q: Won’t medication errors be prevented if nurses just follow the “Five Rights?”
A: Many nurses during their training have learned about the “five rights” of medication use: the right patient, drug, time, dose and route.
However, the “five rights” focus on the nurse’s individual performance and does not reflect that responsibility for safe medication use lies with multiple individuals. Although the “five rights” serve as a useful check before administering medications, there are many other contributing factors to a staff member’s failure to accurately verify the “five rights,” despite their best efforts. For more detailed information, see the following articles.
•“Nurses’ rights regarding safe medication administration” ISMP Medication Safety Alert!® Nurse Advise-ERR July 2007
•The five rights: A destination without a map ISMP Medication Safety Alert!® Jan. 25, 2007
•“The five rights cannot stand alone” ISMP Medication Safety Alert!® Nurse Advise-ERR November 2004
•The “five rights” ISMP Medication Safety Alert!® April 7, 1999
ISMP report.
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