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This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.

This qualitative study demonstrated marked similarities between nurse and consumer perspectives for safe patient identification. Technical aids, such as wristbands and photographs, were deemed important but not replacements for the nurse–patient encounter.