SummaryThis multifaceted program consists of seven relatively simple, inexpensive interventions that are based on safety measures used in the airline industry: (1) a focused protocol and checklist on how to properly administer medications, (2) a quiet (no interruption) zone to retrieve/prepare medications with tape marking off the area, (3) education of staff and physicians to not distract and to "field" interruptions for nurses who are administering medications, (4) the wearing of a special vest or sash designed to signal to others the need to avoid distracting the nurse during medication preparation/administration, (5) use of quiet zone signs on medication room doors and above medication dispensing machines to remind others not to interrupt during medication preparation and administration, (6) nurse education about no conversation during medication administration unless it is about medications, and (7) patient education/orientation about the meaning of the vest and the process. A quasi-experimental evaluation showed that both the focused protocol/checklist and the checklist-vest combination significantly reduced the number of distractions experienced by nurses.Moderate: The evidence consists of a nonrandomized, three-group design to test the effects of two interventions to reduce nurse distractions during medication administration.
Developing OrganizationsA 520-bed acute care for-profit hospital located in a metropolitan city in southeast Texas (hospital anonymity assured by Institutional Review Board).
Date First Implemented2001
Problem AddressedMedication errors and preventable adverse events are significant problems in the U.S. health care system that are often caused by distractions and an inability to focus.
- A common, costly problem: The Institute of Medicine reports that medication errors injure 1.5 million people and costs billions of dollars annually.1 For its part, University Health System found that medication errors were a widespread problem that seemed to be getting worse.
- Distractions and lack of focus as major causes: Medication administration errors are commonly the result of systems problems and other environmental factors affecting nurses, including distractions that make it difficult to focus and follow standard operating procedures. The nursing unit is especially vulnerable to a multitude of interruptions and distractions that affect staff memory and ability to focus during critical times. Methods that prevent and/or reduce these environmental effects on nurses can help avert medication errors.2
Description of the Innovative ActivityThis multifaceted program consists of seven relatively simple, inexpensive interventions that are based on safety measures used in the airline industry. As of February 2013, these seven interventions (expanded from an original list of five) include: (1) a focused protocol and checklist on how to properly administer medications, (2) a quiet (no interruption) zone to retrieve/prepare medications with tape marking off the area, (3) education of staff and physicians to not distract and to "field" interruptions for nurses who are administering medications, (4) the wearing of a special vest or sash designed to signal to others the need to avoid distracting the nurse during medication preparation/administration, (5) use of quiet zone signs on medication room doors and above medication dispensing machines to remind others not to interrupt during medication preparation and administration, (6) nurse education about no conversation during medication administration unless it is about medications, and (7) patient education/orientation about the meaning of the vest and the process. A quasi-experimental evaluation showed that both the focused protocol/checklist and the checklist-vest combination significantly reduced the number of distractions experienced by nurses. Key elements are described below:
- Protocol with checklist: Nurses on one unit use a protocol (known as MedSafe©) that includes a checklist of key things they are supposed to do to ensure proper administration of medications. Checklist items include the following: putting on the visible attire; verifying orders; not engaging in conversation; looking at items being read; checking the seven "rights" of medication administration (right patient, right drug, right dose, right time, right route, right reason, and right documentation); taking the medication administration record to the patient's bedside; taking medications in unit-dose packets to the bedside; verifying the name on the patient arm band; asking the patient to state his/her name; and correctly documenting that medications are given (updated February 2013).
- "Quiet zone" for medication retrieval and preparation: The hospital designated areas for medication retrieval and preparation to be "quiet zones" “safe zones” or “no interruptions zones” where staff are not to be interrupted (updated February 2013).
- Education: Other unit staff members are instructed not to interrupt or distract nurses administering medications unless the distraction relates to the medications being administered. Staff are also instructed, to the extent possible, to intercept phone calls and other distractions for the nurse during medication administration.
- Use of red vest to signal other staff: Nurses on a second unit use the MedSafe© checklist and also wore a red vest or sash with the lettering "MedSafe Nurse, Do Not Disturb" placed on the front and back. The vest is intended to serve as a visible signal to others that the nurse is administering medications and should not be disturbed. As with the other intervention group, unit employees are instructed not to disturb nurses wearing the vest, and to intercept their phone calls and other distractions to the extent possible. The medication safety vest or sash is put on in the medication room and worn only during the medication administration process.
- Quiet zone signs: Signs are posted on medication room doors and above medication dispensing machines to remind others not to interrupt staff members who are retrieving and/or preparing medications.
References/Related Articles(added February 2013) Lewis T, Smith CB, Williams-Jones P. Tips to reduce dangerous interruptions by healthcare staff. Nursing 2012;65-67.
(added February 2013) Pape TM. The role of distractions and interruptions in operating room safety. Perioperative Nursing Clinics 2011;6(2):101-111.
(added February 2013) Pape TM, Dingman SD. Interruptions and distractions during anesthesia induction. Plastic Surgical Nursing Journal 2011;32(2):1-8.
(added February 2013) Trossman S. No interruptions, please. American Nurse: The Official Publication of the American Nurses Association 2010 July/August;1:6-7.
Relihan E, O'Brien V, O'Hara S, et al. The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Qual Saf Health Care 2010;19:e52. [PubMed]
Pape TM, Richards B. Stop knowledge creep. Nurs Manage. 2010;41:8-11. [PubMed]
Westbrook J. Landmark study finds medication errors increase with interruptions. University of Sydney. Sydney Australia. April 2010. Available at: http://www.usyd.edu.au/news/fhs/607.html?newsstoryid=4825
The Sterile Cockpit Concept in Nursing Practice. In: Sculli GL and David Sine DM. Soaring to success: taking crew resource management from the cockpit to the nursing unit. Philadelphia: HCPro, Inc., 2011.
Pape TM. First do not distract. In: Pillow M and Smith V, editors. The nurses role in medication safety. Oakbrook Terrace, IL: The Joint Commission; 2007.
Pape T. What was I doing? JCAHO Patient Safety Newsletter. 2007 April.
Pape T. Workaround error. Case & Commentary. AHRQ WebM&M [serial online], 2006 February. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=118
Pape TM, Guerra DM, Muzquiz M, et al. Innovative approaches to reducing nurses' distractions during medication administration. J Contin Educ Nurs. 2005;36(3):108-16. [PubMed]
Pape TM. Applying airline safety practices to medication administration. Medsurg Nurs. 2003;12(2):77-93. [PubMed]
Pape TM. The effect of nurses' use of a focused protocol to reduce distractions during medication administration [dissertation]. Houston, TX: Texas Woman’s University; 2002.
Contact the InnovatorTheresa (Tess) M. Pape, PhD, RN, CNOR, CNE
Executive Director, ATRANE.org
Adjunct Professor online
Indiana Weslayan University, Marion, IN 46953
Adjunct Professor online
Lamar University, Beaumont, TX 77710
Web site: http://www.atrane.org/
Innovator DisclosuresDr. Pape reported that her organization received funding from Texas Woman's University and that she has received payment for the use of her research instruments from various organizations. Additionally, Dr. Pape’s spouse is involved with sales and distribution of the vest developed in Queensland, Australia that was based on the initial 2001 study.
ResultsBoth the focused protocol/checklist and the checklist-vest combination significantly reduced the number of distractions experienced by nurses.
Moderate: The evidence consists of a nonrandomized, three-group design to test the effects of two interventions to reduce nurse distractions during medication administration.
- Fewer distractions: The number of distractions in the control group totaled 484, compared with just 180 among nurses using the protocol/checklist (meaning that 63 percent fewer errors occurred in the intervention group) and 64 among those using the protocol and vest (87 percent fewer errors).
- Improvement across all categories of distractions: The most common distractions in all three groups consisted of interruptions from other staff and/or the nurse speaking to someone about something not related to medication administration. However, the frequency of such distractions was much lower among nurses using the checklist and staff education and the checklist-vest-education combination. For example, there were 154 distractions caused by other staff in the control group, compared with just 84 among nurses using the protocol/checklist and 29 among nurses using the protocol and vest. Comparable figures related to nurse-initiated distractions (i.e., conversations with others about issues not related to medication administration) were 155 in the control group, 50 in the protocol/checklist group, and 10 in the protocol and vest group.
Context of the InnovationThe program was implemented by an anonymous 520-bed acute care hospital in southeast Texas in response to data showing that medication errors were a major problem area and that nurse distractions were a frequent contributor to these errors. The program was developed based on previous research at Texas Woman's University that showed promising results from adapting airline industry principles to the medication administration process.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Obtaining Institutional Review Board and hospital permission to conduct the study: Approval was obtained for the original study from Texas Woman's University Institutional Review Board. Permission for this study was granted in writing from the study hospital's administration office.
- Defining a medication administration cycle: For evaluation purposes, a nurse's medication administration cycle was defined as the time the nurse begins administration of all assigned patients' medications to the time the nurse completes charting of the medications administered.
- Development of data collection instruments: A demographic data form was developed to collect information from the nurses regarding age, gender, ethnicity, level of nursing education, years of nursing experience, and self-reported level of nursing expertise. The Medication Administration Distraction Observation Sheet, a 10-item instrument used to count nurses' distractions during medication administration, was developed based on a literature review of common sources of distraction, including a physician, other personnel, phone call, other patient, visitor, missing medications, emergency situation, conversation, and external noise.
- Collection of baseline data: A medical–surgical unit was used during the weekdays for observing and counting the number of distractions during a nurse's medication administration cycle. The study was conducted over a 6-day period that included 24 medication cycles.
- Education: Nurses in the intervention groups received brief training and education about use of the protocol/checklist and the vest. Other staff on these units received brief instructions about not distracting the nurses during medication administration.
Resources Used and Skills Needed
- Staffing: No additional personnel are necessary for the innovation. However, collaboration with the quality department, nursing administration, and nurse managers is needed to implement and sustain the project.
- Costs: There are minimal costs associated with the innovation; the hospital developed the red vests at a cost of $7 per vest.
Funding SourcesThe program was funded internally. The original research was funded by a grant from the John Carter Foundation of Texas Woman's University.
Getting Started with This Innovation
- Conduct a baseline evaluation: Quantify and categorize distractions encountered by nurses administering medications.
- Start with one nursing unit: Gradually roll out to other units as they are ready.
- Leadership support: Ensure that registered nurses understand that the hospital is committed to the new solutions and will help them overcome any barriers that might slow the process down.
- Inform key players: Ensure that other stakeholders (e.g., patients, physicians, pharmacists) understand the rationale and the benefits of the changes. Ask to be put on the agenda of each of the different staff meetings affected by the process. Explain the importance of the process, and use previous success data to sell the idea.
- Invest in education about the initiative: Review the entire process with every shift at the start of each shift for the first week, then review once a week with each shift for the next 3 weeks.
- Provide staff education: Furnish one-on-one training and observation of nurses for at least one medication pass during the first week. Using peers to conduct this training is ideal if there are early adopters and process champions available. Nurses who have achieved success often have tips and tricks to offer other nurses (e.g., on how to handle persistent interrupters).
- Provide patient education: Add the medication safety information to patient orientation packets and verbally orient patients to the process when admitted to the unit.
Sustaining This Innovation
- Tracking compliance: Charge a nurse manager on each unit with tracking and monitoring compliance in using the protocol checklist and the vest.
- Expect resistance: Expect some initial resistance among nurses to wearing a visible item like the red or lime green vest. Over time, nurses will likely adjust, and hospital staff will become respectful of the nurse wearing the vest, particularly as they recognize the importance of minimizing distractions to patient safety.
- Consider offering incentives: Offer rewards and incentives for program success.
- Data collection and evaluation: Collect and evaluate data on the number and type of distractions and medication errors that occur on an ongoing basis.
- Include leadership: Conduct leadership "walkarounds" several times a month, especially during the first few months of the program.
- Use of signs: Add a sign on the medication door, above medication dispensing machines, and in hallways to help reduce the number of persons entering the medication dispensing area. The signs provide a reminder to others that this should be a quiet area, and, if possible, interruptions should wait until later. The recommended sign reads "Stop, Quiet Zone, Do Not Disturb Nurses During Medication Administration; Avoid Conversation in this Area."
Additional Considerations and Lessons
- A multifaceted program that includes focused protocols, an outwardly visible sign (e.g., red or lime green vest or sash; "Do Not Disturb" signs on nursing units), education, and teamwork can decrease distractions during medication administration and thus has the potential to decrease medication errors.
Use By Other OrganizationsInformation provided in February 2013 indicates the following use by other organizations:
- Parkview Health in Fort Wayne, Indiana has implemented the MedSafe process with the use of a vest.
- Texas Health Presbyterian Denton Hospital, Denton, TX uses the process but with a red folder instead of a vest or sash.
- Texas Health Presbyterian Hospital Plano, Plano, TX uses the process with a sash.
- Wyoming Medical Center in Casper, Wyoming uses a similar process with a lanyard.
- Kaiser South San Francisco Hospital in California implemented a similar program in 2006 based on Dr. Pape's research, which led to the virtual elimination of nurse distractions for those wearing the vest and a 47 percent reduction in medication errors over a 6-month period.
- Other adopters include:
- The Joanna Briggs Institute, Queensland, Australia
- Changi General Hospital, Republic of Singapore
- John Hopkins Hospital, Baltimore, MD
- St. James's Hospital, Dublin, Ireland
- Dr. Pape continues to be contacted almost monthly about this innovation by researchers and hospital quality department personnel and asked for advice on implementation. Many organizations have requested permission and have used the Medication Administration Distraction Observation Sheet (MADOS) instrument developed by Dr. Pape. Some other facilities working on implementation include: Midland Memorial Hospital, Midland TX; Princeton Healthcare System; Princeton, NJ; Children's Hospital of Philadelphia, Philadelphia, PA; New York-Presbyterian Hospital, New York, NY, and UC Health University of Cincinnati Medical Center.
- A vest with the words “Medication Round in Progress - Please Do Not Disturb” was created in Queensland Australia based on Dr. Pape’s 2001 study and is now available in the US through Riskologic.com at http://www.riskologic.com
1 Institute of Medicine. Preventing medication errors. Washington, DC: The National Academies Press; 2007.
Pape TM. Applying airline safety practices to medication administration. Medsurg Nurs. 2003;12(2):77-93. [PubMed]
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 08, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.