A Guide for Nurses: When Should the Three MAR Medication Checks Be Performed?

Globally, medication-related errors are responsible for 5% to 41.3% of all hospital admissions [1.4.1]. To combat this, a foundational safety process for nurses is understanding when should the three MAR medication checks be performed to ensure accuracy and protect patients from harm.

Quick Summary

This article details the three critical checkpoints for medication administration against the Medication Administration Record (MAR) to prevent errors and enhance patient safety. It covers each check, the 'Rights of Medication Administration,' and the role of technology.

Key Points

• First Check: Verify the medication against the MAR when retrieving it from its storage location [1.2.2].

• Second Check: Verify the medication against the MAR again while preparing the dose (e.g., pouring, drawing up) [1.2.4].

• Third Check: Verify the medication against the MAR a final time at the patient's bedside just before administration [1.3.1].

• Integrate the 'Rights': At each of the three checks, confirm the 'Rights of Medication Administration' (right patient, drug, dose, route, time, etc.) [1.3.5].

• Technology as a Tool: Use eMAR and barcode scanning (BCMA) systems to enhance, but not replace, the manual three-check process [1.7.5].

• Prevent Errors: The primary goal of the three checks is to prevent medication errors, which are a significant cause of patient harm [1.4.3].

• Patient Identification: The third check must include positive patient identification using at least two identifiers [1.5.2].

The Critical Importance of Medication Safety

Medication administration is a core responsibility of nursing, but it carries significant risk. Medication errors are a serious public health concern, harming millions of people and costing the healthcare system billions of dollars annually [1.4.2]. In the United States alone, an estimated 7,000 to 9,000 people die each year as a result of a medication error [1.4.3]. These errors can occur at any stage of the medication process, from prescribing and transcribing to dispensing and administration [1.8.5]. To mitigate these risks at the point of care, nursing practice has established a critical safety standard: the three checks of medication administration. This systematic process requires the nurse to verify the medication against the Medication Administration Record (MAR) at three distinct points. Adhering to this practice is fundamental to preventing errors and ensuring the right patient receives the right medication safely.

When Should the Three MAR Medication Checks Be Performed? A Step-by-Step Breakdown

The three checks are a deliberate, repetitive process designed to catch potential errors before they reach the patient. Each check occurs at a different phase of the medication administration workflow [1.2.1, 1.3.1].

First Check: Retrieving the Medication

The very first check happens before preparing the medication, as you retrieve it from the medication dispensing system (like a Pyxis machine), a drawer, or a shelf [1.2.2, 1.5.2].

1. Obtain the MAR: Access the patient's electronic (eMAR) or paper MAR.
2. Locate and Retrieve: Find the correct medication.
3. Compare: Compare the medication label directly against the MAR. You are verifying the patient's name, the drug name, the dose, the route, and the time of administration [1.3.5]. This initial check ensures you have selected the correct drug from the start.

Second Check: Preparing the Medication

The second check occurs during the preparation of the medication, before you go to the patient's room [1.2.4]. This could involve pouring a liquid, drawing a dose into a syringe, or putting pills into a medicine cup [1.5.2].

1. Prepare the Dose: As you prepare the required dose, pause.
2. Compare Again: Once more, compare the medication label to the MAR [1.3.1]. If it's a pill, compare the container. If it's a liquid you've just drawn up, compare the vial it came from. This step is crucial for catching calculation or preparation errors.

Third Check: At the Patient's Bedside

The final and most critical check happens immediately before administering the medication to the patient [1.3.1].

1. Perform Patient Identification: Use at least two patient identifiers (e.g., asking for name and date of birth, scanning their wristband) and verify this information against the MAR [1.5.2, 1.6.5].
2. Final Comparison: For the third time, compare the prepared medication and its label against the MAR one last time before the patient takes it [1.2.1].
3. Provide Education: Inform the patient about the medication they are receiving and its purpose [1.5.3].

Integrating the 'Rights' of Medication Administration

The three checks are the when and the 'Rights of Medication Administration' are the what. At each of the three checks, you are verifying these rights [1.3.5]. While originally five, these rights have been expanded to include several others to enhance safety [1.2.2, 1.6.6].

• The Core Rights:
  • Right Patient: Is this the correct individual? [1.6.4]
  • Right Medication: Is this the drug that was ordered? [1.6.4]
  • Right Dose: Is the dosage correct and appropriate for the patient? [1.6.4]
  • Right Route: Is it being given via the correct route (e.g., PO, IV, IM)? [1.6.4]
  • Right Time: Is it the correct time for the dose? [1.6.4]
  • Right Documentation: Is the administration being documented accurately and immediately after giving it? [1.6.6]
• Expanded Rights:
  • Right Reason/Indication: Is there an appropriate reason for the patient to receive this medication? [1.3.6]
  • Right Assessment: Have you performed any necessary assessments (e.g., checking blood pressure, or a lab value) before giving the drug? [1.3.3]
  • Right Response/Evaluation: Are you monitoring the patient for the desired effect and for any adverse reactions? [1.3.6]
  • Right to Refuse: The patient has the right to refuse medication after being properly educated [1.2.2].
  • Right Education: The patient has a right to be educated about the medications they are taking [1.5.3].

Comparison Table: Three Checks vs. The 'Rights' of Medication Administration

Concept	Purpose	Primary Question Answered	Application
The Three Checks	A procedural framework to enforce safety	WHEN do I verify the medication?	Performed at three specific points: retrieval, preparation, and bedside [1.3.1].
The 'Rights'	A list of critical data points to verify	WHAT information do I verify?	The set of facts (patient, drug, dose, etc.) that must be confirmed during each of the three checks [1.3.5].

The Role of Technology in MAR Checks

Modern technology plays a significant role in reinforcing the three checks and reducing errors. Electronic Medication Administration Records (eMARs) and Barcode Medication Administration (BCMA) systems are designed to support this process [1.7.5]. A 2025 study showed that implementing technologies like automated dispensing cabinets (ADC), BCMA, and smart dispensing counters (SDC) can reduce dispensing errors by up to 77.78% [1.7.4].

• eMAR: Provides clear, legible orders, reducing transcription errors [1.7.5].
• BCMA: Requires the nurse to scan the patient's wristband and the medication barcode. The system then automatically verifies the 'Rights' of administration, alerting the nurse to any mismatch before the drug is given [1.7.5]. One study found that BCMA implementation reduced medication administration errors by 41.4% [1.7.5].
• Automated Dispensing Cabinets (ADCs): These computerized cabinets help ensure the correct medication is retrieved by requiring user identification and linking to the patient's profile [1.7.4].

While these technologies are powerful tools, they do not replace the nurse's critical thinking and diligence. They are an added layer of safety to support, not supplant, the fundamental process of the three checks.

Conclusion

Understanding when should the three MAR medication checks be performed is non-negotiable for safe nursing practice. Performing the check at retrieval, during preparation, and at the bedside is a foundational habit that drastically reduces the risk of medication errors. By integrating the 'Rights of Medication Administration' into each of these checks and leveraging available technology, nurses act as the final, crucial safeguard for patient safety, preventing harm and ensuring therapeutic and effective care.

For more information on medication safety best practices, visit the Institute for Safe Medication Practices (ISMP) [1.9.1].

Frequently Asked Questions

What is the first check of medication administration?

The first check is performed when you are retrieving the medication from the dispensing cabinet or storage area. You compare the medication label to the Medication Administration Record (MAR) [1.2.2, 1.5.2].

What is the third check of medication administration?

The third and final check occurs at the patient's bedside, immediately before you administer the medication. It involves one last comparison of the drug to the MAR after confirming the patient's identity [1.3.1].

How many rights of medication administration are there?

Traditionally there were five rights (patient, drug, dose, route, time), but the concept has expanded in modern practice to include additional rights like right documentation, right reason, right response, and right to refuse, often totaling 10 or more [1.2.2, 1.6.6].

Does using a barcode scanner replace the three checks?

No. Barcode Medication Administration (BCMA) is a tool to augment and add a layer of safety to the three checks, but it does not replace the nurse's responsibility to perform them manually. Technology can help reduce errors but does not eliminate the need for diligent nursing practice [1.5.3, 1.7.5].

What should a nurse do if a patient questions their medication?

If a patient questions or expresses concern about a medication, the nurse should stop and not administer it. The nurse must review the order, explore the patient's concerns, and, if necessary, notify the prescribing provider before proceeding [1.5.2].

Why is it important to check the MAR three times?

Checking the MAR three times at different stages of the process (retrieval, preparation, and administration) creates a system of redundant checks designed to catch errors. A mistake missed at one point may be caught at the next, significantly improving patient safety [1.2.3].

What is the difference between the 'three checks' and the 'rights of medication'?

The 'three checks' refer to when in the workflow a verification happens (at retrieval, preparation, bedside). The 'rights of medication' refer to what specific information (right patient, drug, dose, etc.) you are verifying during each of those checks [1.3.5].