“Red Zone Medication Safety Initiative” by Jennifer Engel for OPENPediatrics

“Red Zone Medication Safety Initiative” by Jennifer Engel for OPENPediatrics


Red Zone Medication Safety Initiative, by
Jennifer Engel, Beverly M. Small, and Ruth Brediger. [ALARM SOUNDING]
[CELL PHONE RINGING, MOM ANSWERS AND STARTS CONVERSATION]
[ANOTHER NURSE WALKS IN AND INTERRUPTS BEDSIDE NURSE ASKING FOR UPDATE ON THE PATIENT] Jen,
can you give me an update on your patient for report tonight? She’s doing well. We’re just … her. And really nothing major going on today. [BABY CRYING]
How are the parents doing? The parents are great. [PAGER PHONE RINGS]
8 South. This is Jen. Oh, she’s doing OK. She just got an echo this morning. Yeah, overall she’s doing pretty well. She’s very stable. No, I don’t think she’s quite ready to get
… yet. OK. I will. I’ll call you as soon as I hear from them. [TELEVISION NOISE]
[AN ARRAY OF DISTRACTING NOISES] Medication errors are a preventable cause
of morbidity, mortality, and escalating health care costs and therefore are a continued concern
across the spectrum of health care. A major contributing factor to medication
errors is distraction at the bedside. Distractions come from the abundance of technology
at the bedside, as well as frequent interruptions during medication administration and verification. In 2008, the Cardiac ICU at Boston Children’s
Hospital developed a nurse-led interprofessional group to create and implement a program-wide
quality improvement process for medication safety. To better understand the relationship between
distraction and medication administration safety, we organized a nurse-led interprofessional
committee to identify factors that led to medication errors, created strategies to reduce
these errors, and implemented a distraction-free practice in the Cardiac ICU. The committee included nursing leadership,
pharmacy personnel, and physicians. We identified four overriding principles with
the goal of creating a distraction-free practice and decreasing medication errors. The four safety principles aimed to empower
the health care team involved in ordering, dispensing, and administering medications;
ensure the cognitive workspace is free of distractions and interruptions; create a work
environment characterized by teamwork and effective communication; educate families
about the importance of a distraction-free medication process. The Red Zone Committee developed several tools
and strategies to support our distraction-free practice. We developed a logo indicating distraction-free
areas. We created Red Zone badges that included the
distraction-free symbol and a common language script for nurses to use with patients and
families. We placed signs and floor decals with the
Red Zone symbol in front of the medication Pyxis stations and medication rooms. We provided education for all staff to minimize
interruptions and distractions to health care providers during medication, administration,
and ordering. And posters were placed in each patient room,
waiting area, and in welcome packets to inform patients and families and ask for their support. Here are some scenarios showing examples of
our Red Zone tools and use in our daily practice. Example Scenario 1: Good morning, family and
staff. To provide a safe environment during nursing
report, we’re asking for a distraction-free time from now until 7:30. Thank you. Baby boy Smith is a three-month-old, three-kilo
patient who came in on Monday for an ASD repair with Dr. Amani. He did very well post-operatively– Hey, Jen. I just need to get ready for rounds. Can you tell me how baby boy Smith’s night
was? We’re actually in the middle of Red Zone for
nursing report. Do you mind coming back in just a few minutes? What’s Red Zone? The Red Zone allows for distraction-free time
for us to exchange important patient information so we don’t forget anything if we’re interrupted. Oh, OK. Sorry for interrupting. I’ll come back when you’re done. Thank you so much. So as I was saying, he did very well on Monday
and is now ready for the floor. Example Scenario 2: Good morning. Good morning. My name’s Jen. I’m going to be taking care of Jacksyn today. How are you guys? We’re good. Good. I’m just going to take a few minutes to double
check some of her medications, so I’ll be in the Red Zone in distraction-free time. But I’ll let you know as soon as I’m done
to answer any questions. OK? Alright, great. Jen, did she get her Diuril last night? Oh, you know, I’m just still in the middle
of checking some of her medications in distraction-free time. I’m happy to answer that question as soon
as I’m done, though, OK? Thank you. Thanks. Jen, did she pee enough last night? Oh, you know what? I just don’t want to make any mistakes with
checking her medication. So just for Jacksyn’s safety, I need to focus
in distraction-free time for just a few minutes. Absolutely. Sorry. Thank you so much for understanding. Great. Looks like all of her drips look good. I’m also out of distraction-free time, so
I can answer any of your questions. What were you asking about? Did she get her Diuril dose last night? She did. She got her Diuril by 8 o’clock, and she had
a really good response from it. And how much did she pee? She was negative about 140 overall, so that’s
great. We’re really happy with how much she’s making
urine. Thank you very much. Sure. She’s doing really well overall. We’re really pleased with how Jacksyn is recovering. Thank you. Alright. Example Scenario 3: Hi, Jen. How are you? I’m totally dying to see you, because I wanted
to show you pictures from the weekend. They came out awesome. Oh, I would love to see them, Vicky. I’m just in the middle of the Red Zone right
now, getting out some meds. Can I catch you at break? Yeah, sounds good. Thanks. Thank you so much. The Red Zone Medication Safety Initiative
allows the nurse safe and protected space and time to perform high-risk activities without
interruptions or distractions. Distraction-free time also includes your shift
report and safety checks at the beginning of your shift. You may ask for distraction-free time to focus
at any time. Just remind your families and staff that you
are performing an important task, and for patient safety you need distraction-free time
to focus. After the implementation of the Red Zone Medication
Safety Initiative, the Cardiac Intensive Care Unit saw a significant decrease in medication
errors. We had about a 30% reduction in the first
year and over 70% reduction in the next four years. Strategies to reduce distractions and interruptions
at the bedside have now been adopted throughout the institution as the hospital has successfully
created a culture of safety and high reliability. The Red Zone Medication Safety Initiative
successfully reduced medication errors by creating a distraction-free practice which
utilizes various tools and strategies. Bringing awareness to the health care providers
about distractions at the bedside was a critical step in empowering staff to adopt the Red
Zone strategies. We continue to assess the success of this
initiative in medication safety, but have also expanded this distraction-free practice
to other patient care activities to reduce risk of patient harm. Thank you for allowing me to share our experiences
with the Red Zone Medication Safety Initiative in the Cardiac Intensive Care Unit at Boston
Children’s Hospital. I hope these tools and principles will allow
you to develop your own safer nursing practices. Please help us improve the content by providing
us with some feedback.

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