The purpose of this study was to: (1) determine specific factors that contributed to medication errors during the identification process of medication preparation and administration, and (2) present these findings as an aid to minimize or eliminate factors which contribute to medication errors.

To conduct this study the descriptive survey was used. Seventeen medication nurses were observed on three medication rounds. A total of 688 patient contacts and 933 prepared medications were observed and tabulated. The tool of research used to collect data was an observation check sheet developed for this study.

The data collected were analyzed under two broad categories: (1) medication identification, and (2) patient identification. The results were computed in percentages to compare individual nurse's and the group's performances.

For medication identification the nurses utilized the standard three check method only 27 per cent of the time. The most frequently used method was the two cheek method which was used 36 per cent of the time. The one check method as used 13 percent of the time with 70 percent of the nurses resorting to this method. Five percent of the time no cheek was made.

The comparison of medication identification on methods observed during the three medication rounds showed that the use of the standard three check method decreased from round one to round two by 7 percent. On round three the use of the standard three check method increased again over round one by 6 per cent and round two by 13 percent.

In the area of patient identification the nurses utilized the standard patient identification only 27 percent of the time. The most frequently practiced method was the use of the patient's spoken name which was 41 percent of the time. The wristband alone was used 6 percent of the time. In 23 percent of the patient contacts the nurses made no attempt to identify the patients by any observable method. Eight percent of the time the nurses used other methods of identifying the patients such as the labels on the door, bed, tray tables, and water pitchers, for identification purposes.

The comparison of patient identification methods during the three medication round showed that the nurses use the standard patient identification method 41 percent of the time on round one. On round two the standard patient identification method dropped 22 percent while the use of the patient's spoken name increased from 29 to 49 percent. On rounds three there was an increase of 8 percent in the standard patient identification. This 8 percent increase was 10 percent below the standard patient identification method used on round one.

It was concluded from this study that the nurses were not using the precautions in medication preparation and administration in accordance with the recommended standards of identification procedures. Based on the findings of this study, recommendations were made for improvement of medication dispensing methods by suggesting that (1) nursing services and hospital administration give attention to the identification techniques used by nurses and measure which may be used in preventing medication errors by means of effective in-service education programs which emphasize safety principles of identification procedures; (2) the wristbands currently in use be re-evaluated as to permanent legibility; (3) further study be given to medication dispensing system and procedures which would eliminate the necessity for nurses to reply upon memory for the name of the medication and of the patient, and (4) a study be conducted to find out the patient's reaction to the nurses' repeated use of wristband for identification purposes.

LLU Discipline





Graduate School

First Advisor

D. Lois Burnett

Second Advisor

(Matilda) Anabelle Mills

Third Advisor

Bessie Wat

Degree Name

Master of Science (MS)

Degree Level


Year Degree Awarded


Date (Title Page)




Library of Congress/MESH Subject Headings

Drug Therapy; Medication Errors; Nursing Care



Page Count

vii; 87

Digital Format


Digital Publisher

Loma Linda University Libraries

Usage Rights

This title appears here courtesy of the author, who has granted Loma Linda University a limited, non-exclusive right to make this publication available to the public. The author retains all other copyrights.


Loma Linda University Electronic Theses and Dissertations

Collection Website



Loma Linda University. Del E. Webb Memorial Library. University Archives