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Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative
Jean Anne Connor1, Jeanne P Ahern, Barbara Cuccovia
1Jean Anne Connor, PhD, RN, CPNP, FAAN, is director of nursing research for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and clinical instructor of pediatrics at Harvard Medical School. Jeanne P. Ahern, MHA, BSN, RN, CCRN, is staff nurse III, Cardiovascular Operating Room at Boston Children's Hospital, Massachusetts. Barbara Cuccovia, MSN, RN, CPON, is nurse manager for the Hematopoietic Stem Cell Transplant Unit of Boston Children's Hospital. Courtney L. Porter, MPH, is Program Administration Manager II for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital. Alana Arnold, PharmD, is director of the Department of Pharmacy, Boston Children's Hospital. Roger E. Dionne, PharmD, is formulary and medication safety manager for the Department of Pharmacy, Boston Children's Hospital. Patricia A. Hickey, PhD, MBA, RN, FAAN, is vice president and associate chief nurse for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and Assistant Professor of Pediatrics at Harvard Medical School.
Implementing a distraction-free medication safety practice significantly reduced medication errors by over 79% in a children's hospital. This approach proved effective and transferable to other units, enhancing patient safety.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Practices
- Medication Error Reduction
Background:
- Medication errors are a persistent challenge in healthcare.
- Institutions prioritize averting errors and fostering a safety culture.
- This study details implementing a distraction-free medication safety practice.
Purpose of the Study:
- To describe the implementation of a distraction-free medication safety practice.
- To evaluate the impact of this initiative on medication events.
- To assess the feasibility and effectiveness of the intervention.
Main Methods:
- A nurse-led interprofessional group developed a quality improvement process.
- A key driver diagram guided the Red Zone Medication Safety initiative.
- Change acceleration process evaluated implementation and impact.
Main Results:
- Significant reduction in medication events: 79.2% (cardiac ICU) and 65.3% (cardiac unit).
- Achieved months with zero reportable medication events.
- Sustained decrease in events reaching patients (33.3% in CICU, 57.1% in CCU).
Conclusions:
- Distraction-free practice is feasible and effective in reducing medication events.
- The interprofessional approach successfully reduced event rates and patient harm.
- The practice was transferable across hospital units and applicable to high-risk areas.
