How to Review a MAR for a Medication Error Using the Five Rights (Free Tool)
You get one table from a medication record that tells you whether there is a case: for each medication, what was ordered next to what was documented as given, scored against the five rights, with the two quotes that prove each discrepancy. Most suspected medication errors either show up in that table or dissolve in it. This post explains where the pieces come from, how to score them, what to do with the cells the record leaves blank, and which documents to request before anyone writes "omitted dose" in a demand letter.
What the record contains
- Physician orders. Drug, dose, route, frequency, start and stop. In an electronic chart these come from the computerized provider order entry system and carry an audit trail of who entered, verified, changed or discontinued each order.
- The MAR or eMAR. The medication administration record: a grid of scheduled times with an initial or a barcode-scan entry for each dose given, and codes or blanks for doses held, refused or not given.
- Pharmacy records. Verification, dispensing, automated dispensing cabinet transactions, and the pharmacy's own error report if one was filed.
- Nursing notes and flow sheets. The narrative around a dose: why it was held, what the patient's vital signs or glucose were, what happened afterward.
- Allergy documentation. The admission assessment, the armband record and the EHR allergy list with the date each entry was made.
How to score the five rights
For every administration, ask whether the text shows a match between the order and the MAR for the patient, the drug, the dose, the route and the time. Three answers are possible, and keeping them separate is the discipline that makes the review hold up:
- OK only when the text itself shows a match.
- Issue only when the text itself shows a discrepancy, with the order quote and the administration quote side by side.
- Unknown whenever the record you have does not say. An unknown is a records request, not a clearance and not a finding.
Issues then get a type: omitted dose, late dose, wrong dose, duplicate, wrong route, administration with no order, allergy conflict, or monitoring gap (an order that required a lab or vital sign before the dose, with no value charted).
High-alert medications
The Institute for Safe Medication Practices maintains a List of High-Alert Medications in Acute Care Settings (current version 2024). Anticoagulants, insulin, opioids and concentrated electrolytes are the classes most often involved in litigation. A deviation involving one of these is not more culpable by itself, but facilities usually have policies for them, independent double checks, pump programming rules, monitoring requirements, and the policy in force on the date is the standard the deviation is measured against.
Build the five-rights grid from pasted records
Paste the orders, MAR or eMAR excerpts, pharmacy records and nursing notes. The analyzer returns a per-medication five-rights grid, typed and quoted issues, ISMP high-alert flags, a dated timeline and a records-to-request list. Free, no login.
Open the Medication Error Analyzer →A worked example (hypothetical)
The facts below are invented for illustration. No real patient, nurse, pharmacist or facility is described.
A 71-year-old woman is admitted with atrial fibrillation and started on a heparin infusion. The order reads: "Heparin 25,000 units in 250 mL, start at 12 units/kg/hr, aPTT every 6 hours, adjust per nomogram." Her charted weight is 68 kg. The eMAR shows the infusion started at 14:10 at a rate of 18 units/kg/hr. The next aPTT is drawn at 02:30 the following morning, more than twelve hours later. A nursing note at 05:00 records "dark stool, MD notified." Allergy list: "NKDA."
Pasted into the analyzer, the heparin row scores right patient OK (name and MRN match in both quotes), right drug OK, right dose issue (order 12 units/kg/hr, administered 18 units/kg/hr, both quoted), right route OK, right time OK for the start. A separate monitoring-gap issue is raised: the order required an aPTT at six hours, and the first value in the text is at twelve. Heparin is flagged as an ISMP high-alert anticoagulant. The timeline places the start, the missing six-hour draw, the twelve-hour draw and the 05:00 note in order. The gaps list asks for the smart-pump log and the pharmacy verification record, since the text does not show whether the 18 was a programming error or a transcription error.
For plaintiff counsel, that row is the case: a high-alert drug, a dose that does not match the order, and a missed monitoring check, each with its quotes. For defense counsel, the same row says what must be found before the facility can respond: the pump log may show the rate was corrected, and the weight used for the calculation may differ from the one charted on admission.
What to request next
- The complete MAR or eMAR for the admission, every medication, scheduled and PRN.
- The eMAR audit trail: user IDs, timestamps, late entries, edits and deletions with original values.
- The order audit trail from the CPOE system: who entered, verified, modified or discontinued each order and when.
- Pharmacy verification and dispensing records, and automated dispensing cabinet transaction reports.
- Infusion pump logs and smart-pump library data for every IV medication at issue.
- Barcode medication administration scan records and override reports.
- Monitoring data tied to the order: flow sheets, glucose logs, INR, aPTT or drug levels, sedation and pain scores.
- Allergy documentation with entry dates.
- Facility policies on the medication class in force on the date, and the incident report and pharmacy medication-error report for the event.
What the tool does not do
The analyzer gives no dosing advice and invents nothing: every date, dose and quote comes from the pasted text. Most rights come back unknown on a short excerpt because the MAR page or the order sheet is not in what was pasted; each unknown names the document that would resolve it. Whether any deviation mattered clinically is for a pharmacist or physician expert. Verify every quote against the page before it goes into a chronology or demand.
Next step: the full admission, every medication, cited to the page
Upload the complete record and get a Bates-cited chronology that places each order, each administration and each monitoring value in order.
Upload the chart →Frequently asked questions
What are the five rights of medication administration?
Right patient, right drug, right dose, right route, right time. A medication error review scores each administration against each of the five, using the order as the standard and the MAR or eMAR entry as the evidence of what was given.
What does a blank MAR cell mean?
It can mean an omitted dose, a dose documented on another sheet, a held dose with the reason charted elsewhere, or an eMAR entry that was later edited. The eMAR audit trail, with user, timestamp, original value and edited value, settles it. Request it before treating the blank as an omission.
Why are some drugs flagged as high-alert?
The Institute for Safe Medication Practices maintains a list of medications that carry a heightened risk of significant harm when used in error, such as anticoagulants, insulin, opioids and concentrated electrolytes. Facilities usually have specific policies for them, so a deviation involving a high-alert drug is a prompt to request the policy that was in force.
Does the free analyzer say whether the error caused harm?
No. It reports what the record says and does not say. Whether a dose, route or timing deviation was clinically significant is a question for a pharmacist or physician expert.
Related: Medication error malpractice and the five rights and insulin errors and hypoglycemia.