Enhancing Medication Safety through Barcode Medication Administration: Using Nursing Informatics to Drive an Acute Inpatient Mental Health Quality Improvement Initiative

by Michelle Danda, PhD RN

Citation: Danda, M. (2026). Enhancing medication safety through barcode medication administration: using nursing informatics to drive an acute inpatient mental health quality improvement initiative. Canadian Journal of Nursing Informatics, 21(1). https://cjni.net/journal/?p=16078

Abstract

Medication errors remain a significant concern in acute mental health and substance use (MHSU) settings, posing risks to patient safety and care quality. The purpose of this article is to share the implementation and evaluation of a nursing informatics-driven quality improvement (QI) project that ran from October 2023 until June 2024, with a subsequent sustainment phase led by unit-based clinical leadership. It targeted improving nursing medication practices using Barcode Medication Administration (BCMA) with Medication Delivery Carts (MDC) at a large general hospital in the Lower Mainland of British Columbia across an 80-bed acute MHSU service. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guideline was used to structure the two-cycle Plan-Do-Study-Act (PDSA) framework. The project aims were designed to standardize medication administration workflows, increase barcode scanning adherence, increase patient engagement, and improve patient safety outcomes. Initial results indicated notable improvements in medication and patient armband scanning rates, although challenges such as workflow inefficiencies, workaround practices, and changes in medication delivery cart availability limited full adoption. Key findings, barriers, and recommendations for sustaining BCMA practices in MHSU acute services are discussed to support nurses’ consistent adherence to medication safety standards.

Background

Medication administration is a critical component of nursing care, particularly in acute inpatient mental health and substance use (MHSU) services. In this care area a large proportion of a nurse’s time per shift is spent on medication-related activities, most prominently medication administration (Glantz et al., 2019, 2023). In acute hospital settings medication administration involves a series of sequential steps to ensure that nurses adhere to standard practice (Martyn et al., 2019). Errors in this process can lead to adverse patient outcomes, increased healthcare costs, and diminished trust in care providers.

Barcode Medication Administration (BCMA), integrated into a Closed Loop Medication Management (CLMM) system, is a key strategy linked to a technological solution to reduce medication errors and ensure adherence to standardized practice. This approach is endorsed by national standards organizations like Accreditation Canada (2019). At a major general hospital in the Lower Mainland of British Columbia, concerns about low scanning adherence, workflow inefficiencies, and medication-related safety incidents resulted in the inclusion of BCMA with Medication Delivery Carts (MDC) as a core focus of a quality improvement (QI) initiative (the CLMM Project). The purpose of this article is to describe the process and evaluation of a BCMA project in which nursing informatics was a key driver of change. The SQUIRE 2.0 guidelines were used to structure the two-cycle Plan-Do-Study-Act framework (Goodman et al., 2016). Lessons learned are shared along with the implementation process, outcomes, challenges, and recommendations for sustained nursing practice improvements.

Problem Description

Despite the organizational policies, health authority-endorsed standardized workflows, and multiple rounds of staff education, BCMA remained low (consistently below 30% for both medication and armband scans) on an adult acute inpatient MHSU service at the largest hospital in Vancouver, BC. Low BCMA adoption contributed to medication errors and inefficiencies in medication administration. Observations by clinical leadership noted frequent workarounds, including bypassing patient armband scanning. This was consistent with challenges reported by Poland et al. (2023) prior to their QI education initiative at another hospital site in 2022 that was also part of this large-scale multi-health organization Clinical and Systems Transformation Project (Vancouver Coastal Health, 2014).

Available Knowledge and Rationale

Barcode Medication Administration (BCMA) reduces errors by ensuring that nurses verify a patient’s identity along with the medication being administered by first scanning a patient identifying wrist band and then a barcoded medication. However, adoption challenges were found to emerge from workflow misalignment, insufficient training, and other organizational barriers (Martyn et al., 2019). Quantitative barcode scanning data and qualitative observation data were used to inform the current state of medication administration practices.

Methods

This quality improvement project applied the Plan-Do-Study-Act (PDSA) cycle and followed the SQUIRE 2.0 reporting guidelines (Goodman et al., 2016). The key performance indicators (KPIs) used as metrics of success included quantitative rates of medication barcode scanning, and patient armband scanning adherence. Qualitative metrics were also used, including clinical leadership observation of staff nurse adherence to endorsed BCMA with MDC workflow supported by an audit checklist, and qualitative survey feedback from nursing staff.

Context

The adult acute inpatient MHSU service is distributed across five units (94 beds) within a large urban tertiary?care hospital in the Lower Mainland of BC. The units provide short?stay and longer?term intensive treatment for adults experiencing acute psychiatric illnesses and co?occurring substance use, including a substantial proportion of involuntary patients certified under the BC Mental Health Act (Government of British Columbia, 1996), as well as individuals with complex medical comorbidities. Both Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs) are part of the nursing care staffing model on these units, providing round the clock care that includes comprehensive mental and physical health assessment, ongoing risk assessment (for suicide, self?harm, violence, elopement, and withdrawal), therapeutic engagement and milieu management, crisis intervention, interprofessional care planning and discharge coordination, and medication administration and monitoring.

The hospital implemented a CST Cerner electronic health record system in November 2022, establishing Barcode Medication Administration (BCMA) with Medication Delivery Carts (MDCs) as the organizational standard for inpatient medication administration, supported by embedded BCMA compliance reports (Vancouver Coastal Health, 2026). Despite this, baseline scanning adherence on the MHSU units remained low, and local observation highlighted a practice culture characterized by standard workflow workarounds including scanning patient identification labels in the care team station instead of patient-worn armbands, accessing medication and preparation in the medication room or care team base rather than consistently using MDCs to complete the workflow at patient point of care. These patterns were compounded by contextual factors common in acute MHSU settings including patient refusal to wear ID bands, high?acuity and psychiatrically complex presentations, frequent off-unit passes, and episodic staffing and leadership turnover, which together created substantial barriers to consistent use of the intended Closed Loop Medication Management workflow (Strudwick et al., 2017).

Intervention

Prior to launching the first PDSA cycle, the project team conducted a comprehensive current?state analysis and reviewed the emerging literature on BCMA implementation, workarounds, and sustainment to inform intervention design. This included an environmental scan of endorsed BCMA workflows across inpatient acute care areas, direct observation of day-to-day medication administration practices on the MHSU units, and a review of existing BCMA education materials used during the original CST Cerner implementation. Consistent with findings from Strudwick and colleagues (2017, 2018), who identified that BCMA-related workarounds often arise when technology and workflows are poorly aligned with clinical realities, and from Poland and colleagues (2023), who documented medication administration workarounds within the same CST project, the local assessment revealed substantial gaps between the intended Closed Loop Medication Management (CLMM) design and actual practice. Standardized workflows existed on paper, but nurses frequently relied on pre-pouring, scanning labels on paper, inconsistent MDC use, and other workarounds that undermined the safety benefits of BCMA.

Cycle 1 – Implementation & Awareness

Guided by this local analysis and by evidence that successful BCMA adoption requires attention to workflow integration, user training, and proactive management of workarounds, Cycle 1 was designed to build awareness and support initial adoption of the endorsed BCMA with MDC workflow. Education was first delivered to clinical leaders, including clinical nurse educators and head nurses, who were oriented to the standardized workflow, underlying safety rationale, and their role in coaching and monitoring staff nurse practice. These leaders then supported delivery of a 20-minute simulation?based education intervention for frontline nurses, over four weeks, from October to November 2023 and additional offerings to reach part?time and night?shift staff. Simulation provided hands-on practice with barcode scanning of medications and patient armbands, navigation and use of MDCs, and point-of-care medication administration in acute MHSU scenarios, while explicitly addressing common workarounds and linking the workflow to patient safety, regulatory expectations, and local medication policies.

Evaluation of Cycle 1

Immediately following simulation education sessions, nurses were invited to provide brief feedback on the relevance and usability of the education, as well as perceived barriers to using BCMA and MDCs as intended. This feedback, together with the observation data and weekly scanning reports, was used to assess behaviour change at the bedside and to identify which components of the intervention (e.g., simulation content, equipment changes, leadership messaging) most strongly influenced early adoption.

Immediately following simulation education sessions, nurses were invited to provide brief feedback on the relevance and usability of the education, as well as perceived barriers to using BCMA and MDCs as intended. This feedback, together with the observation data and weekly scanning reports, was used to assess behaviour change at the bedside and to identify which components of the intervention (e.g., simulation content, equipment changes, leadership messaging) most strongly influenced early adoption.

Medication and patient armband scanning adherence were measured using existing BCMA compliance reports generated from the EHR reporting portal. These reports provided weekly unit-level percentages of medications administered with a corresponding barcode scan and patients whose wristbands were scanned at the time of administration, allowing comparison between the pre-intervention baseline (June – October 2023) and the Cycle 1 implementation period. Data were extracted for each inpatient unit and then aggregated to describe overall trends as well as unit?level variation in response to the intervention.

To complement the EHR-derived scanning data, structured direct-observation audits were conducted between December 2023 and April 2024 on all four units. Nurse educators and head nurses used a standardized online survey tool to capture data focused on key CLMM behaviours, including MDC use on the floor, secure medication storage, preparation of medications at the time of administration, patient ID band use, and the extent to which medications and wristbands were scanned at the bedside rather than through workarounds (e.g., scanning labels affixed to paper). Observers also documented visible leadership presence during medication passes, provision of just-in-time coaching, and environmental or safety factors that influenced nurses’ ability to follow the endorsed workflow. Insights from this evaluation informed the design of Cycle 2, with particular emphasis on strengthening leadership support, addressing persistent workarounds, and formalizing an audit-and-feedback structure for sustainment.

Cycle 2 – Sustaining and Refining

Building on the gains from Cycle 1, the second PDSA cycle shifted the focus toward sustaining improvements and addressing workflow barriers that persisted despite initial training. Data from post-Cycle 1 observations and scanning audits revealed that, while medication and armband scanning rates had increased substantially, variations in adherence and the use of workarounds, such as scanning patient labels printed and placed on an assignment sheet instead of patient worn armbands, remained on some units. To reinforce the organizational commitment to the endorsed standards, operations leaders issued a formal memo outlining expectations for consistent BCMA use and the proper handling of medications within the Medication Delivery Carts (MDCs). After Cycle 2 ended, a sustainment phase emphasized local ownership of audit and feedback structures.

In Cycle 2, the auditing process included three times weekly observations of staff nurses during morning medication times, and weekly scanning rate audits that provided armband and medication rates for each nurse. This allowed clinical leaders to identify deviations quickly and intervene with targeted support. Education also continued, with sessions embedded into orientation for new hires and periodic refreshers and updates for existing staff during key meetings such as safety huddles, to ensure that the standard workflow was continually reinforced despite staff turnover. The same EHR-embedded scanning reports were used to track medication armband and medication scanning rates, enabling comparison to baseline and PDSA period, while acknowledging report limitations.

The emphasis during this cycle was on embedding BCMA into routine clinical practice so that technology use and safety protocols became embedded into daily practice rather than an added task. By pairing active leadership engagement with consistent audits and just in time education, Cycle 2 worked to close the remaining compliance gaps, address practical workflow challenges, and lay the groundwork for long term sustainability of the safety improvements achieved in Cycle 1.

Study of the Intervention

The study of the intervention drew on the same BCMA reports, structured observation audits, and the nurse feedback mechanisms described above, but extended the analysis across both PDSA cycles and into the early sustainment period. Quantitative BCMA compliance data from the EHR were used to examine trends in medication and armband scanning from pre-intervention baseline (June–October 2023), through Cycle 1 and Cycle 2, and into the unit?led sustainment phase.

Qualitative data from the standardized observation checklists, leadership-completed audits, and staff feedback (collected during and after simulation sessions and at the end of each PDSA cycle) were analyzed to characterize workflow fidelity, workaround behaviours, leadership engagement, and the impact of contextual factors such as MDC availability, staffing, and patient acuity. By triangulating these data sources, the team interpreted changes in scanning rates in relation to actual clinical practice rather than as isolated metrics, and used emerging insights to iteratively refine education, leadership strategies, and audit?and?feedback structures across cycles. This approach also supported responsive, rapid correction of workaround behaviours. The emerging challenges identified through one data stream could be validated against the others and addressed promptly within the iterative PDSA framework.

Results

Quantitative Outcomes

At baseline, prior to the Cycle 1 education intervention, barcode scanning adherence across the adult acute inpatient MHSU units was consistently below 30% for both medications and patient armbands. Following the completion of Cycle 1, which combined simulation-based education with regular observation audits and feedback, medication barcode scanning rates rose sharply to over 80%, with several units maintaining near?perfect adherence in the immediate post-education weeks. Patient armband scanning showed a similarly substantial improvement, increasing from below 30% to approximately 79% by the end of Cycle 1. Weekly BCMA compliance reports from June 2023 to April 2024 showed a distinct inflection point after the October 2023 MDC go-live and education, with sustained medication scanning performance largely maintained in the 60–80% range through early 2024, despite some week-to-week variation.

During Cycle 2, which focused on sustainability and closing compliance gaps, scanning rates remained well above baseline, ranging from 70% to 85% for medication scans and between 68% and 80% for patient armband scans. Variability was noted between units, with those experiencing stable leadership and consistent audit feedback demonstrating higher sustained adherence. Sites with significant staff turnover or ongoing workflow disruptions saw greater fluctuations in performance, with occasional dips in scanning rates that prompted targeted educational refreshers.

Qualitative Results

Observation audits in Cycle 1 revealed significant improvements in adherence to the endorsed BCMA workflow immediately following training. Nurses demonstrated more consistent use of Medication Delivery Carts (MDCs), completion of both medication and patient armband scans, and compliance with secure storage requirements. However, observational data also identified continued challenges, including the persistence of some workaround practices such as scanning printed patient labels instead of armbands, particularly during high-acuity periods or when engaging with patients reluctant to wear identification bands.

During Cycle 2, structured weekly audits made by clinical nurse leaders provided deeper insight into the nature of these workflow barriers. Common issues included interruptions during medication times, competing clinical priorities (for example short staffing or critical incidents on the unit) that prompted deviation from workflow steps, and occasional storage of medications outside of MDCs for perceived efficiency. Staff feedback indicated that while most nurses valued BCMA as a patient safety tool, some perceived certain steps as adding to their workload during peak periods. Leadership presence during medication rounds was associated with better adherence, suggesting the value of real-time reinforcement and role-modeling by nurse champions and clinical leaders.

Trends Over Time

The combined data from both PDSA cycles demonstrated that the intervention achieved not only an immediate improvement in barcode scanning adherence, but also a measurable, though slightly attenuated, sustainment of those gains over time. Following Cycle 1, medication scanning rates increased from below 30% at baseline to over 80%. Following Cycle 2 and in early sustainment (approximately September–December 2024) all-unit medication scanning averaged in the low 80% range, with wristband scanning in the low 70s, although unit-level variation persisted. In mid 2025, overall scanning performance began to decline on several units, coinciding with removal or reduced use of MDCs on the floor (due to isolated patient violence-related safety issues) and other operational disruptions, underscoring the dependence of sustained BCMA adherence on workflow-supportive infrastructure and stable leadership?driven audit and feedback processes. This also highlighted the need to create collaborative partnerships to develop alternate or multiple workflows to include periods of time when it might not be safe or practical to bring an MDC out of the nursing station.

Challenges Identified

Despite marked improvements in barcode medication administration (BCMA) with Medication Delivery Carts (MDCs), adherence and workflow standardization were not fully achieved, and several persistent challenges were identified throughout implementation, evaluation, and sustainment.

Workflow Interruptions

Full integration of BCMA with MDCs into daily nursing practice was frequently disrupted by workflow interruptions caused by competing clinical priorities, unscheduled patient events, and environmental factors such as malfunctioning scanners, MDC access issues, high-acuity admissions, or staffing shortages. These pressures often arose during peak medication times and increased the likelihood that nurses would bypass essential steps in the BCMA workflow. Key examples included: preparing medications in advance in the medication room, omitting bedside wristband scans, or rushing administration when patients were waiting to leave the unit for passes or procedures, all patterns consistent with existing research evidence that time pressure and interruptions drive BCMA deviations and errors (Grailey et al., 2023; Koppel et al., 2008).

Workarounds

Workaround practices remained commonplace, even after simulation-based education and leadership reinforcement. Observational audits revealed instances where nurses scanned patient labels affixed to paper documents rather than using patient armbands, especially in situations where patients resisted wearing identification bands or when time constraints were acute. Such workarounds, while often stemming from a desire to maintain efficiency and patient rapport, undermined the intended safety benefits of BCMA by bypassing the closed loop verification process.

Medication Storage

Medication storage practices posed another significant barrier to full CLMM adherence. Although MDCs were designated as the standard for secure transport and storage during medication rounds, audits uncovered occasions where medications were left unattended at care team bases, stored in automated dispensing unit (AUD) bins or makeshift drawers, or removed prematurely and staged on counters in preparation for later administration. These deviations, are consistent with those noted in existing literature on CLMM and BCMA implementation (Burkoski et al., 2019; Shermock et al., 2023). These practices are found to increase the potential for selection and administration errors and compromised medication security, running counter to both organizational policy and nursing regulatory expectations for safe storage and closed-loop processes.

Leadership Turnover

Leadership turnover and fluctuating levels of engagement impacted the consistency and sustainability of the project outcomes. Units with stable leadership, consistent policy messaging, and visible participation in audits, coaching, and feedback generally demonstrated higher and more stable scanning rates, whereas changes in manager or educator roles, or competing portfolio demands showed greater variability, dips in adherence, and slower recovery following operational disruptions. This pattern aligns with evidence that sustained BCMA and CLMM adoption depends on strong, ongoing clinical leadership to maintain expectations, act on data, and support frontline staff in integrating technology into everyday practice (Grailey et al., 2024).

Discussion

The project demonstrates how nursing informatics roles, EHR-embedded audit tools, and workflow-aligned technologies (BCMA and MDCs) can be used to operationalize closed-loop medication management in complex mental health settings. However, barriers related to the unique aspects of the patient population impacted the shift from implementation to adoption. Barriers to adoption include inconsistent workflow integration, leadership instability, and persistent workaround practices that require continued attention. Leadership engagement, ongoing staff education, and robust auditing structures are critical to sustaining improvements.

Lessons Learned

The project yielded several lessons learned that are relevant to sustaining BCMA in acute MHSU settings. Clear accountability structures emerged as essential for consistent adoption of CLMM workflows, particularly when unit-based leaders were identified as responsible for reviewing BCMA reports and following up on non-adherence with individual nurses. Leadership presence and active involvement during medication rounds were strongly associated with better adherence; when clinical leaders were visible on the units and provided real?time coaching and reinforcement, both scanning rates and workflow fidelity improved.

Regular education proved most effective when embedded into routine structures, such as orientation and brief refreshers during safety huddles, rather than delivered as a one-time intervention, helping to maintain skills and expectations despite staff turnover. While education is necessary for this type of practice change, a comprehensive change management approach is integral, including understanding current state workarounds, planning communication strategies, and consideration of developing alternative workflows that allow for regular medication standard adherence. Addressing workflow barriers required collaborative problem-solving with frontline nurses, whose feedback about safety concerns, efficiency pressures, and MDC placement informed pragmatic adjustments that made the endorsed workflow more feasible in a busy psychiatric environment. Finally, accessible and reasonably reliable BCMA data were critical nursing informatics enablers; simple, EHR-derived audit tools allowed leaders to monitor trends over time, identify units at risk of slippage, and target support where it was most needed, even while acknowledging known limitations in report accuracy.

Limitations

There were several important limitations that should be considered when interpreting the findings and using them to inform future implementations. Leadership and staff nurse turnover, along with inconsistent staffing patterns among nurses requiring education, meant that not all clinicians received the intervention with the same intensity or timing, which may have diluted its impact and reduced consistency of practice change. Knowledge gaps among some leaders regarding use of the clinical EHR and embedded BCMA reports constrained their ability to independently monitor adherence and provide data informed feedback, limiting the reach of the intended audit and feedback strategy. In addition, known issues with the accuracy and stability of EHR embedded reporting tools for BCMA meant that some scanning data may have under or over estimated true adherence, particularly during periods of report malfunction or configuration change.

Competing organizational and service specific priorities, including other major initiatives and operational pressures, affected project timelines and at times reduced the capacity of leaders and staff to focus on BCMA related changes. Finally, the audit tools used to assess CLMM adherence, while useful for identifying broad patterns, were not fully optimized to capture nuanced workflow behaviours and specific workaround types, suggesting a need for further refinement of both qualitative and quantitative measures in future work.

Recommendations

Based on the project findings and current evidence on BCMA and CLMM implementation, several recommendations emerged for sustaining and spreading this work in acute MHSU settings. Continuous leadership education on change management, clinical workflow optimization, and effective use of EHR embedded BCMA reports are essential so that formal and informal leaders can champion CLMM, interpret data accurately, and provide timely, informed feedback to direct care nursing staff. This is consistent with reports that leadership engagement and informatics capability are critical to realizing the safety benefits of closed loop systems.

Standardizing CLMM audits to include both quantitative and qualitative indicators can strengthen sustainment and make results more actionable. Quantitative measures should incorporate unit-level medication and armband scanning rates derived from BCMA compliance reports, while qualitative indicators can be captured through structured observations of workflow fidelity, workaround behaviours, and leadership presence during medication rounds (Grailey et al., 2023). This combined approach reflects the evidence that sustained BCMA adoption depends not only on measurable performance metrics, but also on a contextual understanding of how the technology is actually used in practice, including social, organizational, and environmental factors that shape nurses’ behaviour.

Integrating key CLMM practices and BCMA expectations into daily safety huddles and routine team communications can provide ongoing reinforcement, normalize discussion of medication safety issues, and align with recommendations to embed patient safety practices within existing team structures rather than treating them as add on tasks. Addressing workflow barriers requires deliberate, collaborative problem solving with nursing teams, consistent with research showing that workarounds often reflect misalignment between system design and frontline realities. Engaging nurses in redesigning MDC placement, refining scanning sequences, and troubleshooting patient specific challenges can reduce workaround use and enhance buy in. Finally, conducting quarterly performance reviews that combine BCMA metrics with qualitative audit findings can help leaders and informatics teams monitor adherence over time, identify units or periods at risk of slippage, evaluate the impact of changes, and iteratively refine both technology and workflow to support safer, more reliable medication administration in line with CLMM and BCMA evaluation studies.

Conclusion

This SQUIRE-compliant report highlights the outcomes of a quality improvement initiative focused on implementing barcode medication administration (BCMA) with medication delivery carts (MDCs) in acute adult inpatient mental health units in a large general hospital in the Lower Mainland, BC. The project demonstrated that nursing informatics skills and competencies, including systematic retrieval and use of EHR-embedded BCMA reports, combined with structured, real-time observation of nursing practice at the bedside, can be leveraged within a two-cycle Plan-Do-Study-Act (PDSA) framework to improve medication safety behaviours and illuminate the contextual factors that shape BCMA use in complex MHSU settings. A key enabler of this work was a project team that included nurses with informatics knowledge and competency, who were able to translate clinical needs into data and workflow solutions, support leaders to interpret BCMA reports, and adapt interventions in response to emerging trends.

Experience from both cycles underscored the value of hands-on practice by leaders and staff nurses, and timely, unit-level feedback that pairs positive reinforcement and kudos for high performance with clear, supportive corrective feedback when adherence falls short, helping to build trust, engagement, and accountability around BCMA and CLMM data. At the same time, the gains achieved were vulnerable to workflow disruptions, equipment changes, and leadership turnover, emphasizing that ongoing leadership stability, workflow-supportive infrastructure, and continuous evaluation using both quantitative data and qualitative observation remain critical to sustaining BCMA adherence and realizing the full safety benefits of closed-loop medication management over time. This work also highlighted, from the project team’s perspective, how investing in nurses’ informatics knowledge and creating space for iterative, data- informed reflection on practice can sustain energy for quality improvement in a demanding acute MHSU environment.

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Author Information

Michelle Danda, PhD RN

Institution: Vancouver Coastal Health, Vancouver, British Columbia, Canada
Position: Clinical Nurse Specialist, Nursing Professional Practice, Adult Acute Inpatient Mental Health & Substance Use Services
Email: michelle.danda@vch.ca

Biographical Statement

Michelle Danda is a Clinical Nurse Specialist in adult acute inpatient mental health and substance use services with Vancouver Coastal Health. She has expertise in nursing informatics, quality improvement, and medication safety, and leads initiatives focused on assessment and documentation standards, closed-loop medication management, and inpatient mental health nursing practice.