Effectiveness of bar coded medication alerts for elevated potassium

Bar coded medication administration (BCMA), the automated electronic verification of medications by nurses at the patient bedside, provides an additional layer of safety to the process of medication administration in the hospital setting. We performed a retrospective, descriptive study of BCMA alerts for elevated potassium (>5.5 mg/dL) in place within a multihospital healthcare system. Overall, 642 BCMA alerts were analyzed with a 21.3% acceptance rate. In subgroup analysis, we found that the BCMA acceptance rate was 6.9% for patients aged less than one year, and 85.6% for patients aged greater than one year. The major contributing factor to the low overall acceptance rate was the high frequency of alerts in patients less than 1 year of age. Modifications to rules logic may be necessary for this specific population. While BCMA alerts can beneficial, they should be carefully implemented with periodic post-implementation analysis and refinement.