Recently, I was listening to two grade-school teachers discuss school policies regarding sick students. During their conversation, one mentioned "The Seven Rights" school nurses follow when administering medications to children. I had never heard of The Seven Rights, so I quickly looked them up online.
I found the Seven Rights and several corresponding lists. The Seven Rights evolved from an initial list of five. Some authors and institutions recommend lists containing as many as 10 rights, but seven seem to prevail. The Seven Rights include: the right patient, the right medication, the right dosage, the right route, the right time, the right reason, and the right documentation.
The Value of Lists in Medicine
The rights decrease the risks of medication errors. The primary responsibility for employing the rights falls upon nurses as they administer most medications delivered at the direction of medical professionals at higher levels.
Checklists rooted in examples set by the aviation industry have become prevalent in medicine in recent years. Pilots utilize extensive pre- and post-flight checklists for every flight. This protocol has been a critical factor in airline safety for years. Medicine is striving for similar results.
Protocols for patient handoffs, like I-PASS, SBAR and surgical timeouts, are additional examples of medical checklists. (Table 1) The I-PASS and SBAR protocols are for patient transfers from one provider or facility to another.
The information exchanged between staff during a handoff consists of the patient's name, birthdate, doctor's name, a synopsis of the patient's situation, diagnosis, and the procedure or test to be performed. The protocol helps improve the patient's access to correct care, and transfers authority and responsibility for the patient to the next provider or team.
Surgical timeouts are like handoff procedures. A surgical team member is designated to call a timeout before each procedure. The team member says, "Time out," and everyone stops what they are doing to confirm patient and procedure information.
Before proceeding, the team confirms who they are operating on, the procedure, the correct side of the body, the appropriate patient position, and other essential facts.
Why Not Lists in Chiropractic?
The use of lists in medicine reminds me of a system I used and taught as a member and instructor for a practice-management company (KMS) in the ‘90s. The system was a six-point checklist for established-patient visits. (Table 1)
While the KMS checklist originated as a business management tool, it also served to promote quality care. It provided consistency in a clinical world becoming more complex.
For decades, practicing chiropractic was generalized. Doctors treated a wide variety of conditions. Today, chiropractic practice is more complex. Specialization within the field, advances in diagnostic / therapeutic equipment, and enhanced education have evolved the profession. This fact provides significant reasoning for expanding checklists in chiropractic for clinical and management purposes.
I practice in an academic medical setting and utilize checklists. The number of lists is limited, and their content consists of the three to seven most important steps of a clinical process. I find the checklists keep the practice on track, contribute to my interns' learning process, and help assure consistent care.
In his book The Checklist Manifesto Atul Gawande advocates using checklists in medicine and other fields. He describes numerous cases in which hospitals decreased infection rates and medication errors. In some cases, hospitals increased survival and recovery rates. Each success told was the result of using simple checklists.
Medicine is highly regulated, making the development and dissemination of checklists relatively easy. This degree of regulation is not present in chiropractic. Sometimes our only consistency is our inconsistency. Chiropractic practice has always been very individualized, making the development of standard checklists difficult.
But this should not be a deterrent. I encourage doctors to develop checklists for their practices. While consistency profession-wide may not be immediate, consistency within your practice can be.
TABLE 1: EXAMPLES OF CHECKLISTS IN HEALTHCARE
|The Seven Rights||To reduce errors in administering medications.||Identify:
The right patient, the right medication, the right dose, the right time, the right route, the right reason, and the right documentation.
|I-PASS||Patient handoff procedure||Provide information to the next provider / department on:
I = Illness severity
P = Patient summary
A = Action list
S = Situation, awareness, and contingency plan
S = Synthesis by receiver
|SBAR||Patient handoff procedure||Provide information to the next provider / department on:
|Surgical Timeout||Ensure the correct patient receives the proper procedure at the right site.||Identify:
The correct patient, the correct side, the correct procedure, the correct position, the correct equipment, the correct consent, the correct images, the correct medications and fl uids, and the correct precautions.
|6-Point Established Patient Visit Checklist||To provide consistency during follow-up visits.|| — Ask the patient how they are doing
— Tell the patient how they appear
— Adjust the patient and grade the adjustment
— Offer encouragement
— Introduce/discuss maintenance care
— Confi rm the patient’s next appointment
To start, select three clinical and three business-related procedures, and develop a short checklist for each. The checklists can be for the most critical procedures, frequently overlooked processes, or new methods you wish to implement. Develop each list as a pneumonic to make the list easier to remember.
Once the checklists are in use, refine them as necessary; then develop additional lists. I guarantee this effort will better organize your practice, your patient care will be more consistent, and you will be more successful.
- " The Five Rights: A Destination Without a Map." Institute for Safe Medication Practices, Jan. 25, 2007.
- Thompson CJ. "The Seven Rights of Medication Administration: Should There Be More?" NursingEducationExpert.com, August 2019.
- Kats D. 101 Things That Worked So Well I Had to Stop Doing Them. Levi Publishing, 2000.
- Gawande A. The Checklist Manifesto: How to Get Things Right, New York: Picador, 2009.
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