Abstract
Achieving optimal compliance for bar code medication administration (BCMA) in mature medication use systems is challenging due to the iterative system refinements over time. A nursing leadership initiative increased BCMA compliance, measured as a composite across all hospital units, from 95% to 98%, discovering unanticipated benefits and unintended consequences in the process. The methodology used provides valuable insight into effective strategies for BCMA optimization with applicability for other, similar quality improvement initiatives.