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Recommended Citation
Cooper L, Oechler C, Smith A. The Barcode Breakthrough: A Quality Improvement Initiative to Medication Safety. Quality Improvement podium presentation at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Presentation Notes
Quality Improvement podium presentation at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Abstract
Background
Medication errors affect over one million people annually, leading to significant mortality. Barcode Medication Administration (BCMA) reduces errors by reinforcing safe medication practices. In December 2023, a Midwest non-profit hospital identified BCMA compliance below the 97% (stretch goal 98%) system goal on two medical-surgical (MS) units, prompting intervention.
Local Problem
In Quarter Four 2023, BCMA compliance rates on two inpatient MS units were 91.5% and 94.6%. Issues in data accuracy were identified and addressed in January 2024, ensuring reliable tracking. Data was refined to include only core MS nursing staff. Once data accuracy was confirmed, barcode scanning compliance remained below target on both units (February 2024, 93.3% for MS3; 94.6% for MS5), prompting intervention.
Method
A Plan-Do-Study-Act (PDSA) cycle was initiated. Biweekly reviews revealed usability errors with BCMA, including frequent overrides. Although compliance data was shared during staff meetings, rates remained below target. To enhance engagement, the strategy was revised to include posting individual compliance rates on unit huddle boards and conducting one-on-one coaching for staff falling below 98%. Staff achieving 100% compliance received public recognition.
Results/Conclusions
From June-December 2024, MS3’s compliance increased by 6.4%, rising from 92.9% to 99.3%, while MS5 improved by 3.4%, from 95.5% to 98.9%. The largest month-over-month gain occurred between July and August for MS3 (+4.7 points) and between June and July for MS5 (+1.7 points). By the end of 2024, both units consistently exceeded the 98% stretch goal. This trend was sustained into 2025.
Implications for Practice
Continued posting of BCMA adherence rates on unit huddle boards has maintained high performance while fostering friendly competition. Nurses regularly check the boards, monitoring progress and taking pride in meeting or exceeding compliance goals. As a result, sustained improvements were observed, with both units maintaining compliance rates above stretch.
Document Type
Oral/Podium Presentation
Publication Date
11-12-2025
The Barcode Breakthrough: A Quality Improvement Initiative to Medication Safety
Background
Medication errors affect over one million people annually, leading to significant mortality. Barcode Medication Administration (BCMA) reduces errors by reinforcing safe medication practices. In December 2023, a Midwest non-profit hospital identified BCMA compliance below the 97% (stretch goal 98%) system goal on two medical-surgical (MS) units, prompting intervention.
Local Problem
In Quarter Four 2023, BCMA compliance rates on two inpatient MS units were 91.5% and 94.6%. Issues in data accuracy were identified and addressed in January 2024, ensuring reliable tracking. Data was refined to include only core MS nursing staff. Once data accuracy was confirmed, barcode scanning compliance remained below target on both units (February 2024, 93.3% for MS3; 94.6% for MS5), prompting intervention.
Method
A Plan-Do-Study-Act (PDSA) cycle was initiated. Biweekly reviews revealed usability errors with BCMA, including frequent overrides. Although compliance data was shared during staff meetings, rates remained below target. To enhance engagement, the strategy was revised to include posting individual compliance rates on unit huddle boards and conducting one-on-one coaching for staff falling below 98%. Staff achieving 100% compliance received public recognition.
Results/Conclusions
From June-December 2024, MS3’s compliance increased by 6.4%, rising from 92.9% to 99.3%, while MS5 improved by 3.4%, from 95.5% to 98.9%. The largest month-over-month gain occurred between July and August for MS3 (+4.7 points) and between June and July for MS5 (+1.7 points). By the end of 2024, both units consistently exceeded the 98% stretch goal. This trend was sustained into 2025.
Implications for Practice
Continued posting of BCMA adherence rates on unit huddle boards has maintained high performance while fostering friendly competition. Nurses regularly check the boards, monitoring progress and taking pride in meeting or exceeding compliance goals. As a result, sustained improvements were observed, with both units maintaining compliance rates above stretch.
Affiliations
AMC-Kenosha