Identifying the ‘right patient’: Nurse and consumer perspectives on verifying patient identity...

Feature Article_739 371..379

Identifying the ‘right patient’: Nurse andconsumer perspectives on verifying patientidentity during medication administration

Teresa Kelly,1,2 Cath Roper,2 Stephen Elsom2 and Cadeyrn Gaskin3

1Northern Area Mental Health Service, Melbourne Health, 2Centre for Psychiatric Nursing, The University ofMelbourne and 3The Centre for Quality and Patient Safety Research, Deakin University, Melbourne, Victoria,Australia

ABSTRACT: Accurate verification of patient identity during medication administration is an impor-tant component of medication administration practice. In medical and surgical inpatient settings, theuse of identification aids, such as wristbands, is common. In many psychiatric inpatient units inVictoria, Australia, however, standardized identification aids are not used. The present paper outlinesthe findings of a qualitative research project that employed focus groups to examine mental healthnurse and mental health consumer perspectives on the identification of patients during routinemedication administration in psychiatric inpatient units. The study identified a range of differentmethods currently employed to verify patient identity, including technical methods, such as wristbandand photographs, and interpersonal methods, such as patient recognition. There were marked simi-larities in the perspectives of mental health nurses and mental health consumers regarding theiropinions and preferences. Technical aids were seen as important, but not as a replacement for thetherapeutic nurse–patient encounter.

KEY WORDS: consumer perspective, medication administration, mental health, patient identifica-tion, psychiatric inpatient unit.

INTRODUCTION

Improving patient identification in health-care settings is apriority for international and national patient safety orga-nizations (Australian Commission on Safety and Qualityin Health Care 2008; 2009; The Joint Commission 2011;WHO Collaborating Centre for Patient Safety Solutions2007). The Joint Commission (2011) and the WHOCollaborating Centre for Patient Safety Solutions (2007)recommend that on admission, at least two identifiers be

determined for every patient for the purpose of verifyingthat patient’s identity throughout the episode of care. TheAustralian Commission on Safety and Quality in HealthCare (ACSQHC) upheld the identification wristband asan important technical aid in patient identification andoutlined specifications for a standard national identifica-tion band for use in private and public hospitals acrossAustralia (Australian Commission for Safety and Quality inHealth Care 2008a; 2008b; 2008c; Australian Commissionon Safety and Quality in Health Care 2008). The specifi-cations were endorsed by the Australian Health Ministersthat same year (Australian Commission on Safety andQuality in Health Care 2009).

In Australian non-mental health settings, such asmedical and surgical inpatient units, the use of identi-fication aids (e.g. wristbands) is common. In Victoria,Australia, despite the nurse regulatory authority statingthat for the purpose of duty to care and to prevent harm,

Correspondence: Teresa Kelly, Northern Area Mental HealthService, c/The Northern Hospital, 185 Cooper Street, Epping, Vic.3076, Australia. Email: [email protected]

Teresa Kelly, RN, MHN, PGradDip(AdvClinNursMH), MGest-Ther, BHIM.

Cath Roper, BA, DipEd.Stephen James Elsom, RN, BA, MNurs, PhD.Cadeyrn James Gaskin, BBS(Hons), MBS, PhD.Accepted December 2010.

International Journal of Mental Health Nursing (2011) 20, 371–379 doi: 10.1111/j.1447-0349.2010.00739.x

© 2011 The AuthorsInternational Journal of Mental Health Nursing © 2011 Australian College of Mental Health Nurses Inc.

nurses must make sure that ‘all patients have appropriateidentification such as wristbands’ or photographs (NursesBoard of Victoria 2007, p. 2), in most public psychiatricinpatient units, identification aids are not used. TheACSQHC (Australian Commission for Safety and Qualityin Health Care 2008b) stated that when patients refuse orare unable to wear an identification band, ‘risk-assessedalternatives’ (p. 2) should be employed. Anecdotalreports, however, suggest that nurses working in psy-chiatric inpatient units in Victoria employ a variety ofnon-risk-assessed practices to identify patients duringmedication administration.

Failure to correctly identify patients during medicationadministration results in medication errors (AustralianCommission on Safety and Quality in Health Care 2008;2009; WHO Collaborating Centre for Patient Safety Solu-tions 2007). Medication administrations made in errorcan reduce the effectiveness of treatments, cause adversedrug reactions, lead to the deterioration of health, andthreaten the lives of consumers (Grasso et al. 2003; Hawet al. 2005). There is an urgent need to determine effec-tive ways of identifying patients to improve medicationsafety in psychiatric inpatient units.

In keeping with the ideals of shared leadershipbetween health-care staff and consumers in the design ofhealth systems (Bate & Robert 2006), it would make senseto seek the perspectives of both mental health consumersand mental health nurses towards the identification ofpatients in psychiatric inpatient facilities. In using suchan approach, the chances of developing solutions to theproblem of correctly identifying patients during medica-tion administration might be maximized.

The purpose of this study was to investigate nurse andconsumer perspectives on verifying patient identityduring medication administration. We examined consum-ers’ experiences of being identified during medicationadministration, their opinions of alternative forms of iden-tification (e.g. wristbands, photographs), and their prefer-ences for how they would like to be identified duringmedication administration. We also explored nurses’current practices for identifying patients during medica-tion administration, their opinions of alternative forms ofidentifying patients (e.g. wristbands, photographs), andtheir preferred methods of identifying patients duringmedication administration.

Throughout this paper, we use the terms ‘mental healthconsumer’ and ‘patient’. We use the term ‘mental healthconsumer’ when we refer to people who have a livedexperience of accessing mental health care at some point intheir lives. We use the term ‘patient’ when we refer spe-cifically to people in the context of an inpatient admission.

METHODS

Ethics approvalThe study progressed following approval by The Univer-sity of Melbourne’s Human Research Ethics Committee.

ParticipantsFlyers advertising our research were used to recruit con-sumer (n = 9) and nurse (n = 13) participants to this study.The nurse participants met the following inclusion crite-ria: (i) registration with the Nurses Board of Victoria; (ii)current clinical practice in psychiatric inpatient units; and(iii) roles that included medication administration prac-tice. The inclusion criteria for consumer participants werethat they had: (i) experienced an episode of inpatientpsychiatric care; and (ii) been the recipients of the nursingmedication administration practice in psychiatric inpa-tient settings. Consumers who were being treated in inpa-tient settings, those residing in community care facilities,and those on community treatment orders were excludedfrom this study, because participation during episodes ofcare had the potential to cause unnecessary burden anddistress.

DesignWe employed focus groups to explore the experiences,opinions, and preferences of nurses and consumerstowards methods of correctly identifying patients duringmedication administration. We used similar questions forthe consumer and nurse focus groups. The main ques-tions for participants in the nurse focus groups were:

1. What are your current practices for identifyingpatients during medication administration?

2. What are your opinions of alternative forms of identi-fying patients during medication administration (e.g.wristbands, photographs)?

3. What are your preferred methods of identifyingpatients during medication administration?

The main questions for participants in the consumerfocus group were:

1. What were your experiences of being identified duringmedication administration?

2. What are your opinions of alternative forms of identi-fying patients during medication administration (e.g.wristbands, photographs)?

3. What are your preferences for how you would like tobe identified during medication administration?

The focus groups were audio-taped and transcribed ver-batim prior to content analysis.

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ProceduresWe advertised our research to nurses through theVictorian branch of the Australian College of MentalHealth Nurses, and to consumers through the VictorianMental Illness Awareness Council. The study wasexplained to the research participants (both verballyand in writing), and informed consent was gainedbefore the focus groups began. Participants werereminded that the researchers were interested in learn-ing about a broad range of experiences and opinions.Throughout the focus groups, the moderators concen-trated on engaging participants in interactive discussion,while at the same time, guiding conversations in a waythat encouraged all participants to contribute to thediscussions.

The focus groups were audio-taped and transcribedverbatim. The transcripts of the focus groups were used inthe data analysis.

AnalysisWe performed content analysis on the focus group tran-scripts. Content analysis is a ‘data reduction and sense-making effort that takes a volume of qualitative materialand attempts to identify core consistencies and meanings’(Patton 2002, p. 453). Three of our research team (TK, amental health nurse; CR, a mental health consumerresearcher; CG, a social scientist) synthesized themesfrom the data using an inductive framework. We thendiscussed our interpretations of the data and came to aconsensus regarding the themes present in the data.Finally, we compared and contrasted the findings to iden-tify the similarities and differences between the perspec-tives of nurses and consumers.

Although yielding rich, qualitative data, the discursiveand interactive nature of the focus groups did presentsome challengers for the researchers. Specifically, thevoices of individual participants in the audio-recordingswere unable to be accurately matched to particular quo-tations. Therefore, the quotations presented within thispaper are representative of several participant voices andcannot be attributed definitively to individual focus groupparticipants.

RESULTS

Description of current practicesThe study revealed a range of technical and interpersonalapproaches used to verify ‘right patient’ during routinemedication administration.

Technical methodsTechnical methods for verifying ‘right patient’ identifiedby nurses and consumers included the use of wristbandsand photographs.

Nurses reported that most patients admitted to publicpsychiatric inpatient units were not routinely providedwith a wristband. Where wristbands were used, theiruse was inconsistent. The exceptions to this were thosepatients who were scheduled for electroconvulsivetherapy (ECT) or those who had been issued with awristband in another area of the hospital, such as theemergency department (ED), prior to their transferto the psychiatric inpatient unit. Nurses and consumersdescribed the use of wristbands and/or photographs asroutine practice in psychiatric inpatient units in agedpersons’ mental health, correctional, and private hospitalsettings.

Interpersonal approachesInterpersonal approaches for verifying patient identitydescribed by nurses and consumers included patient rec-ognition and knowing the patient, checking with thepatient, checking with another nurse, and conversing withthe patient.

In public adult and adolescent psychiatric inpatientunits where technical identification aids were not used,nurses described ‘patient recognition’ as an approachcommonly used to verify patient identity. Essentially, thisapproach relied on the nurse who was administering themedication knowing the patient. Nurses explained thatknowing the patient incorporated a range of levels: thefirst, simply being able to visually recognize the patient;the second, remembering the patient in relation to theirmedication regime; and the third, knowing the patient ina deeper and more holistic way informed by the nurse–patient relationship, the quality of rapport, and knowl-edge of the patient’s personal narrative.

Consumers reported that staff ‘seemed to know’ whothe patients were and described being individuallysought out by nurses at medication administration times.Some added that there were often no additional checksto verify patient identity prior to medication beingadministered.

‘Checking with the patient’ involved the nurse askingthe patient for identification details and cross-checkingthe information provided by the patient with the identi-fication information recorded on the medication chart.Nurse participants reported, however, that in practice,this method was flawed when nurses failed to have themedication chart with them at the time of medicationadministration.

IDENTIFYING THE ‘RIGHT PATIENT’ 373


‘Checking with another nurse’ was described as animportant part of verifying patient identity, particularly inthose psychiatric inpatient units where technical identifi-cation aids were not used. This method involved clarifyingthe patient’s identity by asking another nurse who knewthe patient.

‘Conversing with the patient’ during medicationadministration was identified by nurses and consumers asan important part of verifying patient identity. Nursesreported that conversing with the patient incorporated avariety of approaches, including calling the patient’sname, using the patient’s name in conversation, andengaging in therapeutic conversations with the patient.

Several consumers were familiar with nurses callingout the patient’s name as the sole method used by nursesto verify patient identity. Some described an activeinvolvement in verifying patient identity during the medi-cation administration process. This involved the patientdrawing on their personal knowledge of their medicationregime and checking the medication that nurse adminis-tered to them to be sure it was correct:

I’d just woken up when I heard my name called, and Iknew what I was taking, and I knew that all the tabletswere spot on.

Similarly, nurses reported that conversations withpatients during medication administration provided anopportunity for patients to ‘pick up’ potential errors rel-evant to verifying ‘right patient’.

Opinions about current practicesOpinions on technical methodsIn the opinion of nurses working in private psychiatricinpatient settings, requesting patients to wear a wristbandwas appropriate, given the unit was located within thehospital setting:

Patients are within a hospital setting . . . so it’s probablyquite appropriate to put name tags on their wrists.

Likewise, nurses working in aged persons’ psychiatricinpatient units were of the opinion that wristbands wereappropriate in that setting. Some nurses attributed theacceptability of wristbands to the patient’s familiarity withwristbands from previous admissions to inpatient units ingeneral health-care settings.

Nurses working in aged persons’ mental health inpa-tient units described the challenges associated with theuse of wristbands with patients who were distressed oragitated. These nurses emphasized the importance of pri-

oritizing the patient’s needs and exercising clinical judg-ment in decisions regarding whether or not a wristbandshould be applied:

I just suppose it was about what was going on for her atthe time . . . we were trying to build up a rapport andtrusting relationship and (the wristband) wasn’t a priorityat that point in time.

The nurses’ discussion of the routine use of wristbandsfor patients scheduled for ECT highlighted an apprecia-tion of the contribution of the wristband to patient safetyin the context of ECT, and the existent contradiction innot extending these same concerns to verification ofpatient identity during medication administration:

It’s interesting though . . . we put wristbands on peoplewhen they have ECT, and often their response is . . . ‘Atleast they’ll know you have the right person’.

Consumers had mixed views regarding the use of wrist-bands. Some supported the use of wristbands as an impor-tant safety measure, but expected that there would alwaysbe some people who would prefer not to wear them:

It’s inevitable with all the patients . . . that go through thehospital that you’re going to get a percentage (of) wrist-bands which get ripped off.

In contrast, other consumers viewed wristbands andother technical aids as potentially dangerous instrumentssupporting an impersonal and coercive system:

But the step up from those plastic wrist things is likecompletely attached, a prison collar . . . you can justimagine the process . . . the wristbands get put on, theyget taken off, and they’ll go: ‘Well, we could go a stepfurther here’.

Nurses working in public adult and adolescent psychi-atric units described a culture of wristband non-use thatwas informed by many nurses’ beliefs that in psychiatricinpatient units, the nurses know who the patients are. Thestrength of the cultural influence upon the non-use ofwristbands in public psychiatric inpatient units was cap-tured in one nurse’s telling of a conversation betweenherself as a nurse new to a psychiatric inpatient unit andanother nurse who had worked in the unit for some time:

I’ve even been told when . . . I’m new to the ward . . . thatthey don’t want it to appear like a hospital; they don’t wantpeople to feel institutionalized. . . . They would prefer notto have name bands on everybody. . . . I haven’t askedanybody in a senior position, but that was told to me byanother nurse when I asked her. . . . so it’s not meant to

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feel like a surgical ward . . . they want to make it more likea home environment, that sort of thing.

A belief that wristbands contributed to stigma andpatient distress was another characteristic of the culturewhere wristbands were not used:

Anyone who . . . was perhaps suffering paranoid schizo-phrenia is unlikely to want . . . anything which they think. . . there might be a chip in it or something . . . thatwould just add to their distress, suspiciousness.

Nurses described an assumption held by many nursesthat patients do not want to wear wristbands and thatsome patients would actively remove the bands. In con-trast, other nurses felt that often the ‘patients don’t mindthem, (and) most of the time, it’s the nurses whodon’t . . . put them on’.

One consumer, experienced in working with nurses inthe capacity of consumer consultant, reported negativeattitudes expressed by some nurses about consumers inrelation to wristbands and the impact this attitude had onprogressing medication safety initiatives in one mentalhealth service:

Also the bad attitudes . . . previously as a consumer con-sultant, it came up . . . ‘Oh, we should introduce wrist-bands’. I said, ‘Yes, yes, that’s terrific, I have no problemswith wristbands’, you know, as a consumer consultant, butthen it got stopped in one of the committees, because ‘Ohno, they’ll just rip them off ’ . . . I wouldn’t rip mineoff . . . just the attitude; like I was for it because I readabout medication safety issues, but they just, it was thisattitude in . . . the senior staff . . . ‘No, no, the patientswill just tear them off’. Well, it’s so hard to tear them off,and I don’t think most people would . . . sort of pre-empting what we might do based on prejudice.

Nurses working in public acute psychiatric inpatientunits explained that patients who were admitted to theunit through the ED were often issued with a wristband inthe ED, but that the wristband was often removed bynurses upon admission to the psychiatric inpatient unit:

My experience is . . . patients only come in with wrist-bands if they’ve come through ED. . . . If not, theredoesn’t seem to be a policy of putting them on. I’ve evenseen nurses cut them off, saying, ‘Oh look, that’d beuncomfortable, let’s cut that off ’.

A number of nurses identified the use of wristbands asa ‘standard of quality’ and advocated for the use of wrist-bands in psychiatric inpatient units as medication safetystrategy:

I think I’d be most comfortable with wristbands . . . be-cause that’s what they have in general, and . . . there’s thisstandard of quality and of making sure you’ve got the rightpatient in general, and that is the standard, the wristband.

Some nurses working in public psychiatric inpatientunits were concerned about the lack of formal processesfor verifying patient identity and the impact of this onpatient safety:

Just the way I often see (nurses) just handing medicationsto patients saying, ‘Here’s your medication’. . . . There’sno verification, and I’ve seen a few near misses happen.

The absence of technical methods for verifying patientidentity contributed to some nurses feeling anxious andfearful of making mistakes, particularly when working innew environments:

Giving medication . . . can be quite a nerve-wrackingexperience, making sure that I’m on the . . . five rights. . . identifying a patient is so important . . . and I feelreally nervous sometimes, because the background (I)come from is . . . medical, where everybody wears a wrist-band, so it’s quite easy to be sure that you’re giving themedication to the right person.

Nurses held mixed opinions on the use of patient pho-tographs. They identified a number of challenges associ-ated with the use of patient photographs in practice.These included practical problems associated with takingthe photograph, challenges associated with keeping thephotographs current, the importance of locating thepatient’s photograph with the patient’s medication chart,and concern that taking the patient’s photograph is aninvasion of the patient’s privacy.

Some consumers experienced in the use of photo-graphs accepted the taking of the photograph as a neces-sary part of the information collection associated withadmission to a mental health service:

I found it no trouble at all. . . . By the time I sort of wentinto the . . . private system, I was fairly well prepared tohave my photo taken and . . . yeah, well it didn’t occur tome . . . to be a great intrusion.

Others, however, felt that photographs were an inva-sion of the patient’s privacy and expressed concerns abouthow the photograph might be used in the future:

I just thought forever more that I’d have this photographlingering around this space . . . I found it an invasion.

Opinions on interpersonal methodsNurses differed in their opinions regarding ‘patient rec-ognition’ as a method for verifying patient identity.



Nurses who supported this method claimed that remem-bering patients’ names and faces was not a difficult task.Others challenged ‘patient recognition’ as a safe methodin inpatient units with a high patient turnover, or whennurses who were unfamiliar with the patients were allo-cated to the role of medication administration. Thesenurses argued that the reliance on this method in theabsence of other definitive methods of verification ofpatient identity compromised patient safety:

I think any type of identification that doesn’t positivelyidentify the patient is a risk. . . . There is a margin forerror, and then it’s about whether you feel comfortablewith that margin of error or not.

One nurse emphasized the importance of nurses allo-cated to medication administration roles being familiarwith the patients and with the unit:

If I’ve had the chance to chat with the person and . . . amable to recall who they are, then that’s generally enoughfor me. . . . If I haven’t had that chance . . . I’ll actually asknot to give the medication. If I’m in a situation where I’mrunning the shift and I’m allocating the medication, thenI won’t give it to somebody who doesn’t know the patientswell enough.

Consumers appreciated verification of patient identityas an important part of medication safety. Most consum-ers argued that all methods of verifying patient identityshould be underpinned by the nurse’s personal knowl-edge of the patients:

It shouldn’t become as impersonal as it is. . . . Like may-be . . . when staff cross paths with a patient on the ward, ifthey said . . . ‘Hello James’, you know, acknowledgeyou . . . there would be a rapport, and that would build afamiliarity.

Nurses claimed that ‘checking with another nurse’ wasan important part of verifying patient identity when thenurse administering medication was less familiar withthe patient, the patient had recently been admitted, thepatient was unwilling or unable to provide identificationdetails, the nurse was in doubt of the patient’s identity, orwhen the nurse suspected the patient had provided incor-rect identification details. Nurse participants, however,did acknowledge that workplace contextual issues mightprevent nurses from seeking assistance from other nurses:

I think (nurses) are less likely to go find another nurse toverify the patient, and are more likely to . . . hope that it’sthe right person . . . because there’s a lot of pressure to

get the job done quickly . . . you want to go home, the restof the shift wants to go home, the patients want theirmeds.

Nurses expressed mixed views about asking patientsfor identification details. Some thought that most patientswould cooperate with such requests:

Usually, most consumers are really good if you explain,‘Look, this is just a routine legal thing I need to do. I knowthat I know who you are, but I need to ask you your nameand date of birth’, and everybody’s usually fine and coop-erative with that.

Other nurses were not convinced that all patientswould be so cooperative:

I’ve done quite a lot of shifts in places where I haven’tworked before, picking up the occasional shift in a newenvironment and having to give medication to people that(I’ve) never met before . . . and there’s no way to identifywho they are (and) people that don’t want to tell you whothey are.

Some consumers were familiar with being asked theirdate of birth and did not experience this request as anintrusion. One consumer, however, raised concern aboutwhether asking patients to confirm their date of birth wasa reasonable method for verifying patient identity:

If you’re new on the ward, they’ll ask you for a date ofbirth, just to confirm it with their drug sheet. . . . I meanof course, you still could be anyone, and someonecould’ve overheard . . . a date of birth previously anddoubled . . . you know.

Nurses working in units where technical aids were notused held strong views that conversations with the patientwere a good way to double-check that they were admin-istering medication to the right patient:

If . . . I’m not familiar with the person, I might ask themsomething about the medication . . . ‘How long have youbeen on this one for?’ If they know . . . then generallytheir recognizing their medication gives me an indicationI’ve got the right person. . . . I’ve seen (nurses) who’verealized they’ve identified the wrong person because thatperson’s gone, ‘Oh no, I’m not on this medication’, andthat’s where it’s stopped, and that’s where they’ve realizedthey’ve got the wrong person.

Opinions regarding organizational systems and processesSeveral nurses stressed the importance of policy or guide-lines that outline the expected method for identifying

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patients, and expressed concern that the absence of suchframeworks exposed nurses to the risk of makingmistakes.

Some nurses had experience of primary nursing, whereeach nurse was responsible for all aspects of care for asmall group of patients, including medication manage-ment. These nurses viewed primary nursing as superior tothe common practice in public psychiatric inpatient unitsin Victoria, of allocating a single nurse to the task ofadministering medication to all patients in the unit, whichaccording to one nurse, compromised medication safety:

You can have people lined up waiting for medication. . . standing up at the window, and a couple of peopletalking with you, and you know, was it the person on theleft which was supposed to get the medication or theperson on the right? Or people that kind of look similarand a lot of people in the one area . . . a lot of peopletalking to you at the one time. I’ve definitely seen circum-stances where the medication’s just been handed over tothe wrong person.

Consumers also challenged the appropriateness of thesingle medication nurse approach and advocated fornurses to administer medication to small groups ofpatients to promote a more therapeutic and interpersonalexchange where the nurse knows the patient to whom heor she administers medication.

Suggestions for best practiceSome nurses held the firm view that nurses should knowthe patients to whom they were administering medica-tion, and that primary nursing models were the best wayto achieve this. Others emphasized that the use of iden-tification aids, such as wristbands or photographs, shouldbe routine practice, and that this should be supported byclear policies and guidelines.

A number of nurses proposed that nurses engagepatients as partners in medication safety, and more spe-cifically, educate them on the importance of verificationof patient identity during medication administration, andoffer them choice with regard to method of verification.Some nurses related positive experiences of using indi-vidualized medication units, such as ‘dosette boxes’ withphotographs attached. They also noted the limitations ofsuch systems in high-turnover settings, such as acute inpa-tient units.

Consumers made a number of suggestions to improvethe patient verification process. These included a digitalphotograph printed on the patient’s medication chart,wristbands with a small patient photographs attached, anda computerized swipe card containing patient identifica-

tion details. Some consumers advocated for the use oftechnical aids, such as wristbands and photographs, astechnical backups for the nurses:

You’ve got to have something, a backup as well, so theirphoto and wristband, as well as asking a few questions.You know . . . a couple of different things . . . backup, Isuppose.

Other consumers, however, were concerned that pro-moting technical aids had the potential to further com-promise person-centred care:

I just think these impersonal aids and this scanning of thepatient is dangerously impersonal . . . if you initiatechange in that direction, it’s not going to be as pleasant forthe patient . . . on a friendly or on an open sort of, youknow, emotional level with staff, because by doing that(the nurses will) defer their contact with you and just, youknow, sit in the office. . . .

Consumers agreed that nurses administering medicationto smaller groups of patients would be preferable to thesingle medication nurse system commonly used in psychi-atric inpatient units in Victoria. Like the nurses, consum-ers cognisant with ‘primary nurse’ and ‘contact nurse’systems suggested the application of such approachesto improving patient verification during medicationadministration:

A good way to do it would be to have the nurse dispensethe medication for his group, for his five or six (patients),and then the next nurse would dispense for his group, andso on.

One consumer advocated for a nurse–patient induc-tion upon admission, thereby providing an opportunity forthe nurse to develop a comprehensive and holistic knowl-edge of the patient:

The best thing would be for a friendly induction . . . indi-vidually or in a group. . . . (The nurses) sit down with you,they say ‘hello’, you know; full names, they shake yourhand, and wish you well and, you know, that recognitionwould last your admission.

DISCUSSION

In this study, nurse participants described the routine useof wristbands or photographs as technical identificationaids during medication administration in public agedpersons’ mental health, correctional, and private inpatientpsychiatric units. Nurses working in public adult and ado-lescent psychiatric inpatient units, however, reported thatwristbands were not routinely employed to verify patient



identity during medication administration. Furthermore,when wristbands were used, their use was inconsistent,erratic, and often at odds with a workplace culture thatdid not support the use of technical aids.

When the ACSQHC endorsed the identification wrist-band for use in private and public hospitals across Aus-tralia, they identified the mental health patient populationas an exception (Australian Commission for Safety andQuality in Health Care 2008b). Interestingly, in thepresent study, consumers emphasized the importance ofnot excluding people with mental health problems frommedication safety initiatives by pre-empting what theymight or might not agree to, based on prejudice andstereotypes of people with mental illness.

Consistent with the findings of this study, contempo-rary quality and safety health-care literature emphasizesthe importance of systems, processes, and cultures thatpromote accurate patient identification in all health-caresettings (Australian Commission on Safety and Qualityin Health Care 2008; WHO Collaborating Centre forPatient Safety Solutions 2007).

This study revealed that across public adult and ado-lescent psychiatric inpatient units in Victoria, there is anursing culture of wristband non-use that is embedded intradition and is informed by a belief that, in psychiatricinpatient units, the nurses know who the patients are. Incontrast, the WHO Collaborating Centre for PatientSafety Solutions (2007) maintains that patient identifica-tion must be verified for each patient on each and everycare administration occasion, even when the health-careworker feels familiar with the patient. Furthermore, theyassert the importance of organizational systems andprocesses that emphasize that the health-care provideradministering the care holds primary responsibility forverifying a patient’s identity (WHO Collaborating Centrefor Patient Safety Solutions 2007).

Consistent with earlier studies (Duxbury et al. 2010;Haglund et al. 2004), the researchers in this study foundthat in mental health inpatient settings, nurses knowingpatients and patients knowing nurses is an importantpart of the medication administration process for nursesand consumers. The findings of this study indicate thatin many psychiatric inpatient units in Victoria, the taskof medication administration is allocated to a singlemedication-administration nurse. Nurse and consumerparticipants however, advocated for more patient-centredapproaches that support nurses administering medicationto smaller groups of patients. Furthermore, the nurse andconsumer participants suggested that all methods of veri-fying patient identity should be underpinned by patient-centred practices that incorporate engaging with patients

in a holistic way, informed by the nurse–patient relation-ship, rapport, and knowledge of the patient’s mental,physical, and social health history. The real-world experi-ences of consumer participants, however, suggested thatthis was not always the case.

Engaging patients as partners in medication safety pro-vides opportunity for patients to take an active role inpatient identification and in reducing medication errors(Australian Commission on Safety and Quality in HealthCare 2008; Institute of Medicine 2000; Walrath & Rose2008; WHO Collaborating Centre for Patient SafetySolutions 2007). In this study, nurse and consumer par-ticipants identified nurse–patient interpersonal inter-actions that invite the patients to check their medicationas an important medication error-reduction strategy.

LIMITATIONS

This modest study was limited in scope, and as such, itsfindings should be interpreted with caution. The extent towhich the views expressed by the nurses and consumers inthis study are representative of those of other nurses andconsumers is unknown. Larger-scale research is neededto ensure that any changes to practice are feasible andacceptable to the nurses and consumers affected by suchchanges.

CONCLUSION

This study highlights important implications and raises anumber of challenges for nurses. Challenging culturesthat do not value standardized methods of verifyingpatient identity is fundamental to nurses progressingmedication-safety agendas in mental health settings.Further, nurses must take lead roles in progressing sys-temic, systematic, and multifaceted practice improve-ment initiatives specifically relevant to accurateverification of patient identity during medication admin-istration. At an organizational level, policies and guide-lines must clearly outline the nurse’s legal, ethical, andorganizational responsibilities (WHO CollaboratingCentre for Patient Safety Solutions 2007). At a patientcare level, nurses, patients, and carers need to beinformed of the importance of accurate patient identifi-cation to medication safety. Practices that engage patientsas active partners in medication administration, particu-larly in regard to verifying patient identity, should bepromoted (Australian Commission on Safety and Qualityin Health Care 2008; Institute of Medicine 2000; Walrath& Rose 2008; WHO Collaborating Centre for PatientSafety Solutions 2007).

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Educating patients and their carers (WHO Collaborat-ing Centre for Patient Safety Solutions 2007) about theimportance of accurate patient identification, explainingpolicies, and offering patients practical and realisticchoices about how they would prefer to be identifiedduring the medication administration is a vital componentof progressing patient-centred, safety focused, and prag-matic patient-identification practices.

ACKNOWLEDGEMENTS

The authors thank the Victorian Mental Illness AwarenessCouncil and the Australian College of Mental HealthNurses (ACMHN), Victorian branch, for assistance inrecruiting participants, and Finbar Hopkins for herhelpful comments on an earlier draft. This study wassupported by the 2007 ACMHN and Bristol MyersSquibb Research Grant.

REFERENCESAustralian Commission for Safety and Quality in Health Care

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