Jun 18 2012

Lighting the way to safety

UH Cardiothoracic Unit uses Fostering Innovation Grant to reduce medication errors

In 2010, Clinical Nurse Specialist Regi Freeman, RN, MSN, CNS, began noticing a higher rate of medication errors – incorrect dose, time and route – on the UH 4C Cardiac & Thoracic Surgery unit.

Freeman works with Quality Improvement to enhance patient and family experience as well as nursing practice. The unit she oversees cares for lung and heart transplant patients including those with open heart, valve replacement surgery and ventricular assist devices.

“We started looking into the causes of medication errors and realized our unit administers more medication doses in a one-month period than any other unit in the Health System,” says Freeman. “Patients on 4C often need more than 20 medications per day during their hospital stay.”

Sarah Comstock, BSN, RN gets medicine for a patient in UH 4C's No Interruption Zone.

After interviewing and shadowing staff as well as reviewing the timing and frequency of medication errors, Freeman found that the 70 nurses in 4C were being interrupted multiple times as they counted, prepared and administered medication.

“Interruptions included everything from pages and phone calls from staff, to patients, family members and colleagues stopping nurses in the hallway to ask questions,” Freeman says

Once the cause was clear, Freeman and her team sprang into action to find a solution.

They applied for a Fostering Innovations Grant from the U-M Health System and used funding to create a “No Interruption Zone” in the unit’s medication room.

Fostering Innovation Grants

has awarded funding to all kinds of projects across the U-M Health System including clinical and education initiatives.

“Our number one criteria for FIGs funding is that the idea is innovative,” says Warden. “We also discuss, as a committee, if it can be done and that the budget submitted seems appropriate for the work. If all of those line up, they are likely to get funding.”

Click here to learn more about FIGs.

Outfitted with signs and instructions, the room is now a quiet place where conversations unrelated to medication administration are discouraged.

But that’s not all. Staff working in the room wear flashing lanyards to signify they are administering medicine and should not be interrupted. Lanyards are turned on for the entire process of medication administration, from the time nurses enter the medication room until they reach patients’ rooms to give them medicine.

“The lanyard was an innovative idea and it’s clear to see when a nurse is administering medication,” says Mindy Warden, program manager for FIGS.  “In total, Freeman’s unit was awarded $5,350 for the lanyards and other aspects of the project.”

The “No Interruptions” initiative also involved patient education because the biggest interrupters were patients and their families. Table tent signs on bedside tables explain the lighted lanyards, and staff give each patient welcome a brochure about the initiative.

UH 4C staff wear flashing lanyards to signal to others that they should not be interrupted while counting and administering medicine.

Other measures include providing clerks with a script for phone calls received during peak medication times, asking callers to leave a message unless it is an emergency. Nurse pagers are also only answered in an emergency or once the medication administration process is complete.

“Our goal on 4C was to reduce interruptions during medication administration and improve medication administration safety,” says Freeman. “We hoped this would decrease our overall medication errors.”

Freeman has met that goal: Since the program began, interruptions in 4C have dropped significantly causing medication errors to fall by 50 percent.

2 Responses to “Lighting the way to safety”

  1. Anne Armstrong says:

    This idea has been one of mine for the outpt areas for a long time. I have suggested orange or neon green vests or sashes like the construction folks wear. I hope this idea will also spread to the outpt areas. There needs to be no interruptions when drawing up immunizations in the outpt areas. The med refrigerators in our clinic are in a very congested Team Room.

  2. Erica Dutton says:

    I agree with Anne’s comments. I just read this. A 50% reduction in errors!! WOW. Think of what was saved, not just in money but in impact on patients, families’ and nurses’. Hopefully this will spread throughout the health system.

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