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One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. When a medication error does occur during the administration of a medication, we are quick to blame the nurse and accuse her/him of not completing the five rights. The five rights should be accepted as a goal of the medication process not the “be all and end all” of medication safety. 

 
Judy Smetzer, Vice President of the Institute for Safe Medication Practices (ISMP), writes, “They are merely broadly stated goals, or desired outcomes, of safe medication practices that offer no procedural guidance on how to achieve these goals. Thus, simply holding healthcare practitioners accountable for giving the right drug to the right patient in the right dose by the right route at the right time fails miserably to ensure medication safety. Adding a sixth, seventh, or eighth right (e.g., right reason, right drug formulation, right line attachment) is not the

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