Six Rights of Medication Administration

Category: Concepts Sources: raw/supplemental/emt-b-pharmacology.md, raw/nremt/psychomotor-skills.md Last updated: 2026-04-05

Overview

The Six Rights of Medication Administration is a systematic check performed before every medication is given. It exists because medication errors are one of the most common and preventable causes of patient harm in all of medicine — and the emergency setting, with its time pressure and competing demands, is exactly where errors happen most.

In the prehospital setting, the EMT-B administers a small set of drugs, but the consequences of a medication error can be fatal. Giving aspirin to a patient with a known GI bleed, or giving oral glucose to an unconscious patient, are life-threatening errors that a 15-second rights check prevents.

The classic six are: Right Patient, Right Drug, Right Dose, Right Route, Right Time, Right Documentation. Some sources add a 7th (Right Reason) or expand to 9 rights — these variations are noted below.

The Six Rights

1. Right Patient

Before any medication: confirm you are giving it to the correct patient.

In the prehospital context: - Single-provider calls with one patient: less ambiguity, but still requires confirmation of identity - Multi-casualty incidents (MCI): wrong patient errors are common when multiple patients are present and resources are stretched. Confirm name and date of birth verbally when possible. - Pediatric dosing depends on weight — confirm who you weighed before calculating. - Unresponsive patients: confirm identity from ID, family, or crew documentation before medication administration.

Why it matters: In multi-patient scenes, medications prepared for one patient can inadvertently be given to another. In MCIs, tagging and labeling help — use them.

2. Right Drug

Confirm the correct medication is in your hand before administration.

In the prehospital context: - Read the label twice — once when you pick up the medication, once before administration. - EMT-B scope drugs: oxygen, oral glucose, aspirin, epinephrine auto-injector (EpiPen), activated charcoal. The field is small — but auto-injectors come in adult (0.3 mg) and pediatric (0.15 mg EpiPen Jr) doses. These are physically similar. Check. - Epinephrine auto-injectors: verify it's epinephrine, not a patient's auto-injector that has already been used, is expired, or is a different medication entirely. - Oral glucose preparations: Glutose 15, Insta-Glucose, and other formulations vary by concentration. Know what you're carrying. - Check expiration date — expired medications may be ineffective or harmful.

Why it matters: Look-alike, sound-alike medications exist. In a high-stress environment, a provider can reach for the wrong device, especially if multiple medications are laid out together.

3. Right Dose

Confirm the correct amount of the medication is being administered.

EMT-B scope drug doses:

Drug	Adult Dose	Pediatric Dose
Oxygen	Titrated to SpO2 — NC 1–6 LPM, NRB 10–15 LPM	Same principle; adjust device for size
Oral glucose	12–25 g buccal	12–15 g (weight-dependent); confirm with protocol
Aspirin	162–324 mg chewed	Not typically given in prehospital pediatric setting
Epinephrine auto-injector	0.3 mg IM (EpiPen)	0.15 mg IM (EpiPen Jr) for <30 kg
Activated charcoal	25–50 g PO (adult)	12.5–25 g PO (pediatric)

Why it matters: Underdose may fail to treat the condition. Overdose can cause harm. For pediatric patients, wrong dose is a leading cause of medication errors — weight-based dosing requires verified patient weight and accurate calculation. For epinephrine, giving the adult dose (0.3 mg) to a small child (appropriate dose 0.15 mg) doubles the epinephrine and can cause severe hypertension and dysrhythmia.

Dose confirmation in the field: When possible, have your partner independently verify the dose you calculated before administration. "Two eyes on the dose" catches errors that one fatigued provider misses.

4. Right Route

Confirm the medication is being administered by the correct route.

Routes used in EMT-B scope:

Route	Description	EMT-B Drugs Using It
Oral (PO)	Swallowed; requires conscious patient who can swallow	Aspirin (chewed and swallowed)
Buccal / sublingual	Placed in cheek or under tongue; absorbed via mucous membrane	Oral glucose (buccal smear)
Inhaled	Inhaled via mask or mouthpiece	Oxygen
Intramuscular (IM)	Injection into muscle (vastus lateralis for epinephrine)	Epinephrine auto-injector

Why it matters: - Oral glucose given to an unconscious patient will aspirate — it cannot be safely swallowed without a gag reflex. Route confirmation prevents this fatal error. - Aspirin must be chewed, not swallowed whole — chewing breaks the tablet for faster GI absorption and faster antiplatelet onset. Swallowing whole delays absorption by 15–30 minutes in an ACS scenario where minutes matter. - Epinephrine auto-injector into the lateral thigh, through clothing if needed — not into a vein, not into the buttock, not into a joint. The auto-injector is designed for IM injection, and accidental IV injection of 0.3 mg epinephrine can cause hypertensive crisis and life-threatening dysrhythmia.

5. Right Time

Confirm the medication is being given at the appropriate time — including timing of repeat doses.

In the prehospital context: - "Is this the right time?" — Does the clinical picture match the indication right now? A patient who initially presented with ACS symptoms but has now become unresponsive may have had a cardiac arrest — aspirin timing has changed. - Repeat dose timing: Epinephrine auto-injector may be repeated per protocol (typically after 5–10 minutes if patient does not improve). Do not repeat before that interval; do not delay beyond it if the patient is deteriorating. - Drug timing interactions: A patient who just took aspirin at home ("took two baby aspirin 20 minutes ago") changes the timing decision. Stacking aspirin doses risks GI bleed — this is a contraindication, not just a timing note. - Medication expiration: If the drug is expired, the right time has passed.

Why it matters: Giving the right drug at the wrong time can be as harmful as giving the wrong drug. A second epinephrine dose too soon compounds cardiac effects. Aspirin too late in an ACS doesn't reduce the benefit but an unchecked contraindication can cause active hemorrhage.

6. Right Documentation

Every medication administered must be documented — drug, dose, route, time, and patient response.

What to document: - Drug name (generic and trade if applicable) - Dose administered - Route of administration - Exact time of administration (clock time — "1427" not "during transport") - Patient response to medication (improvement, no change, adverse reaction) - Who administered (your name and certification level) - Authorization received (standing order vs. online medical direction; if online medical direction — document who you spoke to)

Why it matters: - Hospital continuity: the ER cannot safely give additional aspirin, nitroglycerin, or epinephrine without knowing what the EMT-B gave and when. - Legal protection: documentation is your record of what you did and why. "If it wasn't documented, it wasn't done" — this is both a legal and professional standard. - Adverse reaction tracking: if a patient has a reaction to a medication, documentation allows investigation of what was given. - Protocol compliance: NM EMS protocols require documentation of every medication administered, including the authorization pathway.

Verbal report counts too: At patient handoff, include medications given in your report: "Administered 324 mg aspirin chewed at 1427 per standing order; patient reports pain improved from 8 to 6 out of 10; no adverse reaction."

The 7th Right: Right Reason

Many sources now include Right Reason as a 7th right — confirming not just that the indication is technically met but that the underlying clinical rationale is sound.

Example: A patient with chest pain meets the technical criteria for aspirin (chest pain, no known allergy, no prior dose today). But the OPQRST reveals the pain is sharp, pleuritic, and reproducible by palpation — this is unlikely ACS. "Right reason" prompts you to ask: does this patient actually need aspirin, or is the indication being applied reflexively?

This is especially important in EMS because protocols create decision trees that can be followed mechanically. Right Reason adds clinical judgment to the systematic check.

Extended Rights (8 and 9)

Some systems include: - 8th Right: Right to Refuse — Patient has the right to refuse medication. Document informed refusal. See refusal-of-care. - 9th Right: Right Assessment — Confirm your assessment findings actually support the indication before giving the drug.

These are useful concepts but the NREMT cognitive exam tests the core six (or seven with reason).

Applying the 6 Rights to Each EMT-B Drug

Oxygen — oxygen

• Patient: Any hypoxic or distressed patient meeting O2 indications
• Drug: O2 (correct delivery device for the clinical situation)
• Dose: NC 1–6 LPM (mild hypoxia), NRB 10–15 LPM (distress, SpO2 <94%), BVM at 15 LPM for inadequate breathing
• Route: Inhaled (correct mask selection is part of route)
• Time: Administer as indicated; titrate to SpO2; COPD patients target 88–92%
• Documentation: Device, flow rate, time initiated, SpO2 before and after

Oral Glucose — oral-glucose

• Patient: Known diabetic with altered mental status
• Drug: Oral glucose gel (Glutose 15, Insta-Glucose) — not orange juice, not candy (not in the protocol)
• Dose: 12–25 g buccal
• Route: Buccal smear — patient must be conscious and able to swallow; do NOT give to unconscious patient
• Time: As soon as indication criteria are met; reassess BGL at 15 minutes
• Documentation: Drug, dose, time given, BGL before and after, route, patient response

Right Route violation example: Giving oral glucose to a patient who is only responsive to painful stimuli. The patient cannot protect their airway — oral glucose will obstruct.

Aspirin — aspirin

• Patient: Patient with suspected cardiac chest pain (ACS)
• Drug: Aspirin 81 mg or 325 mg tablets — confirm aspirin, not a different tablet
• Dose: 162–324 mg (typically 2× 81 mg or 1× 325 mg)
• Route: Oral — patient must chew (not swallow whole); requires conscious patient with intact swallowing
• Time: As soon as ACS indication met, all contraindications cleared; do not delay for IV access or vitals
• Documentation: Dose, time given, authorization (standing order or name of physician if online MD), patient response (pain scale before and after, any adverse reaction)

Key contraindication check for Right Drug/Right Time: Allergy to aspirin or NSAIDs, active bleeding, patient already took aspirin today, known bleeding disorder.

Epinephrine Auto-Injector — epinephrine-auto-injector

• Patient: Patient with anaphylaxis (systemic allergic reaction)
• Drug: Epinephrine auto-injector (EpiPen adult or EpiPen Jr) — confirm correct device; check not expired
• Dose: 0.3 mg adult / 0.15 mg pediatric (<30 kg)
• Route: IM, lateral thigh (vastus lateralis) — through clothing if needed
• Time: Administer as soon as anaphylaxis with systemic involvement is confirmed; may repeat in 5–15 min per protocol if patient not improving
• Documentation: Which device (adult/pediatric), dose, route (which thigh), time, authorization, patient response (BP, HR, airway improvement, rash resolution)

Right Dose failure example: Using adult EpiPen on a 15 kg child — delivers 0.3 mg when 0.15 mg is correct. Can cause severe hypertension and dysrhythmia.

Activated Charcoal — activated-charcoal

• Patient: Conscious patient who can swallow, with ingested toxin, within 1 hour of ingestion
• Drug: Activated charcoal suspension — confirm it's charcoal (black, gritty texture), not another medication
• Dose: 25–50 g adult / 12.5–25 g pediatric — given orally
• Route: Oral — must be swallowed; patient must be fully conscious and cooperative
• Time: Within 1 hour of ingestion for most benefit; use is declining in many NM systems — verify current protocol
• Documentation: Dose, time given, authorization (online medical direction typically required for charcoal), substance ingested, time of ingestion, patient response

Common Mistakes

• Giving oral glucose to an unconscious patient — Right Route error. This is a patient safety critical fail. If the patient cannot safely swallow, the buccal route is not safe.
• Giving adult-dose epinephrine auto-injector to a child — Right Dose error. Pediatric patients get 0.15 mg (EpiPen Jr), not 0.3 mg adult dose.
• Not documenting the time of medication administration — Right Documentation error. "During transport" is not a time. Document clock time.
• Skipping authorization documentation — Standing order is still an authorization and should be documented as such ("administered per standing order"). If online medical direction was obtained, document the provider's name.
• Assuming the drug is correct without reading the label — Especially important for epinephrine auto-injectors. An expired EpiPen, or a patient's allergy injector (Auvi-Q, different formulation), should be confirmed before use.
• Giving aspirin without checking if patient already took their dose — This is a SAMPLE-M finding that students routinely miss. "Did you take any medications today? Any aspirin or Advil this morning?"

NM Protocol Notes

• NM EMS Treatment Guidelines require documentation of all medications administered, including dose, route, time, authorization, and patient response.
• All EMT-B scope medications require either a standing order (pre-authorized by Medical Director for specific indications) or online medical direction (verbal authorization from a physician during the call).
• Authorization pathway must be documented: "Administered per standing order" or "Authorized by Dr. [name] at San Juan Regional Medical Control at [time]."
• If a medication error occurs: notify Medical Control immediately; document fully on the PCR; file an incident/adverse event report per agency protocol.

NREMT Relevance

High-yield topic for the cognitive exam and skill stations:

• Know all 6 rights by name — the exam will ask "which of the 6 rights was violated when..."
• Know the right route for each EMT-B drug — oral glucose buccal, aspirin chewed, epinephrine IM lateral thigh
• Know which contraindications correspond to which right — aspirin allergy violation is "Right Drug" or "Right Patient"; unconscious patient receiving oral glucose is "Right Route"
• Documentation: the NREMT expects you to verbalize giving a medication AND documenting it in the skill stations
• Repeat dose timing for epinephrine auto-injector is tested: when may you repeat? (5–10 minutes, per protocol, if patient not improving)

Related

• aspirin — Right Drug/Dose/Route details for ASA
• oral-glucose — Right Route emphasis (must be conscious and able to swallow)
• epinephrine-auto-injector — Right Dose critical (adult vs. pediatric)
• activated-charcoal — Right Time emphasis (within 1 hour)
• oxygen — Right Dose involves selecting correct device and flow rate
• sample-opqrst — SAMPLE history provides the information to check Rights 1–5
• refusal-of-care — Right to Refuse (7th/8th right in expanded frameworks)

Sources

• raw/supplemental/emt-b-pharmacology.md — Medication administration guidelines
• raw/nremt/psychomotor-skills.md — Medication administration skill stations