Quiet Zone

A MEDICATION ADMINISTRATION SAFETY INITIATIVE

Quiet Zone

PURPOSE

PICO Question

Population Intervention Comparison Outcome

For nurses administering medications during the 9 am medication pass time, (P) will implementing a “Quiet Zone” (I) as compared to no intervention (C) reduce interruptions and distractions, decrease medication pass time and improve medication safety (O)

STATISTICS

Remain among the most common errors in hospitals (Joint Commission Journal on Quality and Patient Safety 2009)

A hospital patient is subject to at least one medication error per day (Preventing Medication Errors Quality Chasm Report 2006)

Annual costs range between $3.5 to $29 Billion (Joint Commission Journal on Quality and Patient Safety 2009)

7,000 preventable deaths per year (Joint Commission Journal on Quality and Patient Safety 2009)

1.5 million people harmed (Joint Commission Journal on Quality and Patient Safety 2009)

PROCESS IMPROVEMENT

Medication administration is a high volume activity

Workflow Studies: Nurses spend 26.9% of their time on medication related activities (Keohane et al 2009)

A single patient can receive up to 18 medication doses/day. A nurse can administer up to 50 medications/shift (Mayo and Duncan 2004)

Large portion of medication errors occur during administration

PROCESS IMPROVEMENT

Interruptions Frequently Cited by Healthcare Workers

11% of time spent on interruptions in 38 drug rounds (Catchpole et al 2008)

484 distractions during 8 medication cycles (Pape 2003)

374 interruptions during 59 hrs of medication administration, 6.3 interruptions/hr (Biron et al 2009)

Medication Administration: High Risk Activity

5 Risk Points Outlined by

JCAHO Selection, procurement,

storage Prescribing, ordering,

transcribing Preparing, dispensing Administering Monitoring

Nursing involved in last 3 risk points

No Safety Net for Nurses

NURSING WORKFLOWMedication Administration

Interprets electronic MAR

Verifies Patient Information-Allergies, vitals, labs

Pyxis

Medication Refrigerator

Patient Medication Bin at substation

Obtains necessary supplies from substation: IV tubing, labels, syringes, etc

Verifies medications

obtained with electronic MAR at

computer at substation

Enters patient’s room. Washes

hands

Checks 2 patient identifier and

allergies. Administers medications.

Washes hands

Documents medication

administration at computer

Monitor patient for therapeutic and/or adverse

effects

NURSING WORKFLOW 0854-0926 (32 min)

Medication Administration

Interprets electronic MAR

Verifies Patient Information-Allergies, vitals, labs

Pyxis

Medication Refrigerator

Patient Medication Bin at substation

Obtains necessary supplies from

substation: IV tubing, labels, syringes, etc

Verifies medications obtained with

electronic MAR at computer at substation

Enters patient’s room. Washes hands

Checks 2 patient identifier and

allergies. Administers medications. Washes

hands

Documents medication

administration at computer

Patient Medication Bin at substation

Phone

Call to pharmacy re: missing med

Med. refrigerator

Conversation MD

Find RN for Witness

Pyxis

Patient care

Phone call to MD

MD

SCIENTIFIC PRINCIPLES AND THEORIES

Prospective Memory Performance in which an individual

must recall a plan or an intention in the future without a reminder to do so (Grundgeiger et al2008)

Cognitive Work of NursesCognitive Shifts: Shift focus from one

patient to another (Potter et al 2005)

9 shifts/hr=1 shift/6-7 minStacking: cognitive load at any given

time (Potter et al, 2005, Ebright et al 2003)

11 activities at any given moment

NURSING WORKLFLOWStacking and Cognitive Shifts

NURSING WORKFLOW

COGNITIVE SHIFTS

AND

STACKING

REASONS’S HUMAN ERROR MODEL

Active Failures: “Sharp End” Human Factors: knowledge deficit, failure to follow

protocol, lack of experience Influenced by latent conditions

Latent Conditions: “Blunt End” Dormant Error Prone Working Conditions: design deficiencies, time

pressure, distractions and interruptions

Error is the result of alignment of conditionsActive Failures+ Latent Conditions = Opportunity for Error

ACTION PLAN: RESEARCH DESIGN

Design Pilot Study

Setting 41 Bed Telemetry Unit 9 am medication pass

time Sample

Convenience Sample of Nurses

Rollout IRB approved: Aug 2010 To Begin: Oct 2010

Methodology Direct Observation Data Collection:

Interruptions to nurse 9 am medication pass time

Comparison Phase I and Phase II Phase I

Nurse Distraction Perception Survey

MADOS tool No Intervention

Phase II Observation as in Phase I Quiet Zone Intervention

DATA COLLECTION Developed and validated by Dr Tera Pape

Nurse Distraction Perception Survey

Medication Administration Documentation Observation Sheet

MADOS Tool

QUIET ZONE INTERVENTIONS

Signage Demarcation of Pyxis area

and Sign

Nursing Attire: Red arm band indicating medication administration

Staff Education Audience: Nursing,

Nursing Assistants, Physicians, P.T. Unit Secretary, Housekeeping, Lab, Dietary, Transport

Patient and Family Education: letter explaining safety initiative

Do Not Interrupt Nurses During Medication

Administration!Avoid Conversation In This

Area!

QUIET ZONE

QUESTIONS TO BE ANSWERED

Rates and sources of work interruptions Is there a significant difference between the

control and intervention groups

Medication pass time Can medication administration occur in a timelier

fashion with implementation of a “Quiet Zone”

Medication Safety Will there be a reduction in medication error as

evidenced by decrease in number of incident reports after intervention

Can a culture change be effected