Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative

被引:20
作者
Connor, Jean Anne [1 ,2 ]
Ahern, Jeanne P. [3 ]
Cuccovia, Barbara [4 ]
Porter, Courtney L. [5 ]
Arnold, Alana [6 ]
Dionne, Roger E. [6 ]
Hickey, Patricia A. [2 ,5 ]
机构
[1] Harvard Univ, Sch Med, Nursing Res Cardiovasc & Crit Care Serv, Dept Nursing Patient Serv,Boston Childrens Hosp, Cambridge, MA 02138 USA
[2] Harvard Univ, Sch Med, Pediat, Cambridge, MA 02138 USA
[3] Boston Childrens Hosp, Cardiovasc Operating Room, Boston, MA USA
[4] Boston Childrens Hosp, Hematopoiet Stem Cell Transplant Unit, Boston, MA USA
[5] Boston Childrens Hosp, Dept Nursing Patient Serv, Cardiovasc & Crit Care Serv, Boston, MA USA
[6] Boston Childrens Hosp, Dept Pharm, Boston, MA USA
关键词
Patient safety; Prevention of medication errors; Quality improvement;
D O I
10.1097/DCC.0000000000000179
中图分类号
R47 [护理学];
学科分类号
1011 ;
摘要
Background: The incidence of medication errors remains a continued concern across the spectrum of health care. Approaches to averting medication errors and implementing a culture of safety are key areas of focus for most institutions. We describe our experience of implementing a distraction-free medication safety practice across a large free-standing children's hospital. Methods: A nurse-led interprofessional group was convened to develop a program-wide quality improvement process for the practice of medication safety. A key driver diagram was developed to guide the Red Zone Medication Safety initiative. Change acceleration process was used to evaluate the implementation and impact of the initiative. Results: Since implementation in 2010, there has been a significant reduction in medication events of 79.2% (P = .00184) and 65.3% (P = .035) (in the cardiac intensive care unit and acute care cardiac unit, respectively), including months with unprecedented zero reportable medication events. There also has been a sustained decrease in the number of events reaching the patient (33.3% in the cardiac intensive care unit and 57.1% in the acute care cardiac unit). Conclusions: The implementation of a distraction-free practice was found to be feasible and effective, demonstrating a sustained decrease in the overall number of medication events, event rate, and number of events reaching patients. This interprofessional approach was successful in a large inpatient cardiovascular program and then effectively transferred across all hospital inpatient units. Additional sites of implementation include other high-risk patient care areas such as procedure/operative units.
引用
收藏
页码:116 / 124
页数:9
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