Quiet Zone

1. Quiet Zone A Medication Administration Safety Initiative

2. PURPOSE PICO Question PopulationInterventionComparisonOutcome For nurses administering medications during the 9 am medication pass time, (P) willimplementing a “Quiet Zone” (I) as compared to no intervention (C) reduce interruptions and distractions, decrease medication pass time and improve medication safety (O)

3. STATISTICS • Remain among the most common errors in hospitals (Joint Commission Journal on Quality and Patient Safety 2009) • A hospital patient is subject to at least one medication error per day (Preventing Medication Errors Quality Chasm Report 2006) • Annual costs range between $3.5 to $29 Billion (Joint Commission Journal on Quality and Patient Safety 2009) • 7,000 preventable deaths per year (Joint Commission Journal on Quality and Patient Safety 2009) • 1.5 million people harmed (Joint Commission Journal on Quality and Patient Safety 2009)

4. PROCESS IMPROVEMENT • Medication administration is a high volume activity • Workflow Studies: Nurses spend 26.9% of their time on medication related activities (Keohane et al 2009) • A single patient can receive up to 18 medication doses/day. A nurse can administer up to 50 medications/shift (Mayo and Duncan 2004)

5. Large portion of medication errors occur during administration

6. PROCESS IMPROVEMENT Interruptions Frequently Cited by Healthcare Workers • 11% of time spent on interruptions in 38 drug rounds (Catchpole et al 2008) • 484 distractions during 8 medication cycles (Pape 2003) • 374 interruptions during 59 hrs of medication administration, 6.3 interruptions/hr (Biron et al 2009) Medication Administration: High Risk Activity 5 Risk Points Outlined by JCAHO • Selection, procurement, storage • Prescribing, ordering, transcribing • Preparing, dispensing • Administering • Monitoring Nursing involved in last 3 risk points No Safety Net for Nurses

7. NURSING WORKFLOWMedication Administration Verifies medications obtained with electronic MAR at computer at substation Interprets electronic MAR Enters patient’s room. Washes hands Checks 2 patient identifier and allergies. Administers medications. Washes hands Verifies Patient Information -Allergies, vitals, labs Obtains necessary supplies from substation: IV tubing, labels, syringes, etc Documents medication administration at computer Pyxis Medication Refrigerator Patient Medication Bin at substation Monitor patient for therapeutic and/or adverse effects

8. NURSING WORKFLOW 0854-0926 (32 min)Medication Administration Phone call to MD Verifies medications obtained with electronic MAR at computer at substation Call to pharmacy re: missing med Interprets electronic MAR Enters patient’s room. Washes hands Checks 2 patient identifier and allergies. Administers medications. Washes hands Verifies Patient Information -Allergies, vitals, labs Obtains necessary supplies from substation: IV tubing, labels, syringes, etc Patient care Conversation MD Pyxis Pyxis Documents medication administration at computer Patient Medication Bin at substation Medication Refrigerator Patient Medication Bin at substation Med. refrigerator Find RN for Witness Phone MD

9. SCIENTIFIC PRINCIPLES AND THEORIES Prospective Memory • Performance in which an individual must recall a plan or an intention in the future without a reminder to do so (Grundgeiger et al2008) Cognitive Work of Nurses • Cognitive Shifts: Shift focus from one patient to another (Potter et al 2005) • 9 shifts/hr=1 shift/6-7 min • Stacking: cognitive load at any given time (Potter et al, 2005, Ebright et al 2003) • 11 activities at any given moment

10. NURSING WORKLFLOWStacking and Cognitive Shifts

11. NURSING WORKFLOW COGNITIVE SHIFTS AND STACKING

12. REASONS’S HUMAN ERROR MODEL • Active Failures: “Sharp End” • Human Factors: knowledge deficit, failure to follow protocol, lack of experience • Influenced by latent conditions • Latent Conditions: “Blunt End” • Dormant • Error Prone Working Conditions: design deficiencies, time pressure, distractions and interruptions Error is the result of alignment of conditions Active Failures+ Latent Conditions = Opportunity for Error

13. ACTION PLAN: RESEARCH DESIGN • Design • Pilot Study • Setting • 41 Bed Telemetry Unit • 9 am medication pass time • Sample • Convenience Sample of Nurses • Rollout • IRB approved: Aug 2010 • To Begin: Oct 2010 • Methodology • Direct Observation • Data Collection: Interruptions to nurse 9 am medication pass time • Comparison Phase I and Phase II • Phase I • Nurse Distraction Perception Survey • MADOS tool • No Intervention • Phase II • Observation as in Phase I • Quiet Zone Intervention

14. DATA COLLECTION Developed and validated by Dr Tera Pape Nurse Distraction Perception Survey Medication Administration Documentation Observation Sheet MADOS Tool

15. QUIET ZONE INTERVENTIONS Signage Demarcation of Pyxis area andSign Nursing Attire: Red arm band indicating medication administration Staff Education Audience: Nursing, Nursing Assistants, Physicians, P.T. Unit Secretary, Housekeeping, Lab, Dietary, Transport Patient and Family Education: letter explaining safety initiative

16. QUESTIONS TO BE ANSWERED • Rates and sources of work interruptions • Is there a significant difference between the control and intervention groups • Medication pass time • Can medication administration occur in a timelier fashion with implementation of a “Quiet Zone” • Medication Safety • Will there be a reduction in medication error as evidenced by decrease in number of incident reports after intervention • Can a culture change be effected