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Quality Update - Driving Away Distractions

Summer 2010

Driving Away Distractions

Date: July 23, 2010

Two Hopkins teams devise ways to block the interruptions that can lead to medication errors.


yellow safety jackets
Having nurses wear yellow safety jackets was one of the steps that helped a <br/>Hopkins Hospital unit to reduce disruptions during medication administration.

Medication administration is one of the most critical and highly vulnerable tasks that a nurse performs. And yet the process is often besieged by distractions—ringing phones, beeping monitors and questions from other caregivers, to name a few—that only make mistakes more likely.

“We have to start changing the mindset that nurses are always available and make uninterrupted time for them to calculate dosages, program delivery pumps and perform other important tasks,” says Lori Paine, patient safety director at The Johns Hopkins Hospital.

Two recent projects at the hospital have shown promise in reducing distractions and helping to insure that the five “R”s of the administration process—the right patient, drug, dose, route of delivery, and time and frequency—are followed.

On CMSC 9, a floor in the Johns Hopkins Children’s Center, Annette Perschke developed a pilot to study the nature of interruptions and distractions, and then reduce them. A patient safety analyst in the Department of Pharmacy at the time, Perschke found that the most common disruptions to administering medication were another nurse starting a conversation, interruptions by the patient receiving medication, and external noise.

The next step was implementing three interventions: turning off the phone ringer in the main medication room, posting signs that read “Do Not Disturb: Medication Safety Zone” in seven medication storage areas, and creating an educational video that instructed nurses to use a “Stop!” hand signal to ward off nonurgent requests.

By the end of the yearlong project, the number of interruptions and distractions on the floor had decreased by 28 percent. Moreover, nurses there continue to raise their hand as a warning signal whenever they administer medications.

Michelle D’Alessandro, nurse manager of Halsted 8, an adult inpatient unit, also launched an effort last year to protect the five Rs. She recalls that when she first worked on that floor in 1997, medications were stored in the back of the nurses’ station, a commotion-filled spot.

“At that point, there were mostly human distractions,” she says. “Now there are a lot more technological ones: bed alarms, pagers, heart monitors going off, intercoms, electronic people finders—and all those cell phones and Blackberries vibrating.”

And the patients on that floor tend to have complicated conditions that require multiple medications, she says.

Her four-day study of medication administration on Halsted 8 found that distractions and interruptions were reduced 52 percent when no more than three people were allowed inside the medication room at one time, when no call bells or phone calls were permitted, and when nurses wore yellow safety vests to discourage conversation and requests.

Paine would like to see such safety improvement efforts spread throughout the hospital. She says using do-not-disturb signals such as special clothing and hand gestures may help establish the “sterile cockpit” safety environment developed by the aviation industry.

“The rule is that if a plane is below 10,000 feet, or in any critical stage of flight, crew members should restrict communication to only what is necessary to do the job,” she says, pointing out that conversation also ceases whenever a golfer is teeing up or when a cashier is counting a big stack of bills.

“Although those fields have created sacred space to protect their critical processes, that’s not yet consistently present on clinical floors,” she says.

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