Date of Award

Fall 2023

Project Type


College or School




Degree Name

Master of Science

First Advisor

Pamela Kallmerten



Background: Medication errors pertaining to patient wristband workarounds in a behavioral and mental health inpatient unit can affect patient outcomes, safety and can even be fatal. The proper verification of the five rights of medication administration, patient acuity, diagnosis, and unit staffing can impact the need for patient wristband workarounds to occur. Improving staff and patient education and reducing the need for wristband workarounds through the utilization of patient photographic identification significantly reduces the number of medication errors relating to wristband workarounds during the medication administration process. Additionally, a significant reduction in the time it takes to administer medications can be noted.

Local Problem: Registered Nurses (RNs) spend a significant amount of time administering medications on the unit and due to contributing factors such as patient acuity, diagnosis and shortages in staffing can lead to patients presenting to the medication window without their assigned patient identification wristband. Such occurrences make it difficult for the RN to properly verify the five rights of medication administration. These circumstances result in the RN making the decision to perform a barcode workaround. These workarounds directly correlate to an increased risk in medication errors.

Methods: The Plan-Do-Study-Act (PDSA) model was utilized for implementation of this intervention. Tally sheets were utilized to collect data regarding frequency of patient wristband workarounds during both pre- and post-intervention data collection periods. The macrosystem’s “EZ Track” medication error reporting system was utilized to collect data regarding the number of medication errors that occurred and were reported by the RNs. Data from both pre- and post-intervention periods were compared and analyzed for patterns correlation.

Interventions: Patient photographs were taken for newly admitted patients for a two-week period. RNs marked a tally on the tally sheet each time a barcode workaround occurred.

Results: The number of patient barcode workarounds reduced significantly during the post-intervention period, thus resulting in a 75% reduction of medication errors.

Conclusion: Continued investigation into the effectiveness of the medication administration process and utilization of the intervention is recommended to reduce medication errors on the unit.