Our New Q/A Forum Is Here!   Click Here To Start Exploring Now.

Pre Hospital Hub Logo

Medication Checks and Documentation

4 Jun 2024

Tags: Communication | Documentation

Medication Checks And Documentation 

In healthcare settings, ensuring patient safety is paramount, especially when it comes to medication administration. Mistakes in administering medications can have serious consequences for patients. To mitigate risks and uphold standards of care, healthcare professionals should adhere to protocols such as the Six Rights and double checks of medication administration to ensure accurate medication checks and documentation. Additionally, documentation of administered medication should be accurate and completed once administered. These protocols serve as essential safeguards to prevent errors and promote optimal patient outcomes.

Six Rights of Medication Administration

The Six Rights framework provides a systematic approach to medication administration, encompassing key elements that must be verified before administering any medication:

Right Patient

Verifying the patient’s identity through multiple identifiers such as name, date of birth, or hospital identification number ensures that the medication is intended for the correct individual.

Right Reason

Confirming that the medication is being administered for the correct medical indication or reason ensures that it aligns with the patient’s treatment plan and condition.

Right Medicine

Ensuring that the medication being administered is the correct one prescribed for the patient by comparing the medication label against the prescription or medication administration record.

Right Route

Verifying that the medication is administered via the correct route (e.g., oral, intravenous, intramuscular) as prescribed to ensure optimal absorption and effectiveness.

Right Dose

Calculating and verifying the dose of medication to be administered based on factors such as the patient’s weight, age, and condition to prevent under or overdosing.

Right Documentation

Accurately recording all details of the medication administration, including the medication name, dose, route, time of administration, and any observations or reactions noted, ensures comprehensive documentation of patient care.

6 Rights Of Medicine Administration

Double Checks in Medication Administration

In addition to the Six Rights, double checks can further enhance safety and accuracy in medication checks and administration:


Confirming that the patient does not have any known allergies or adverse drug reactions to the medication being administered minimizes the risk of allergic reactions or adverse events.

Other Medicines

Checking for potential interactions with other medications the patient is taking helps prevent harmful drug interactions.

Clinical Observations

Assessing the patient’s clinical status before administering the medication ensures that it is indicated and safe for the patient’s current condition.

Indicated? Contraindications? Cautions?

Reviewing the patient’s medical history and any contraindications or precautions associated with the medication helps identify any factors that may affect its safety or efficacy.


Ensuring that the patient has given informed consent for the medication administration respects the patient’s autonomy and promotes shared decision-making in their care.

Correct Name and Strength

Verifying the accuracy of the medication name and strength prevents administration errors that could result from confusion or mislabeling.

Packaging and Expiry

Checking that the medication packaging is intact, and the contents are suitable for use and within the expiry date, ensures the medication’s potency and safety.

Scope of Practice:

Confirming that the route of administration is within the healthcare provider’s scope of practice and suitable for the patient’s condition prevents errors related to inappropriate administration routes.

Documentation and Double Check

Documenting all medication administration details and performing an independent double check of the medication, dose, route, and expiry enhances accountability and ensures thoroughness in the medication administration process.


Adherence to the Six Rights and double checks of medication administration is fundamental for medication checks and documentation to maintaining patient safety and preventing medication errors in healthcare settings. By following these protocols diligently, the highest standards of care can contribute to optimal patient outcomes.

Continuous education, training, and adherence to established protocols are essential to fostering a culture of safety and excellence in medication administration across all healthcare settings.

Key Points

  • The Six Rights framework and double checks are essential for medication checks and documentation to prevent errors and ensure optimal patient outcomes.

  • Ensuring the correct medication, route, dose, and comprehensive documentation are fundamental in medication administration.

  • Adherence to scope of practice guidelines and documentation standards enhances accountability and patient safety.