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Quiet Zone. A Medication Administration Safety Initiative. PURPOSE. PICO Question P opulation I ntervention C omparison O utcome - PowerPoint PPT Presentation
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A MEDICATION ADMINISTRATION SAFETY INITIATIVE
Quiet Zone
PURPOSE
PICO Question
Population Intervention Comparison Outcome
For nurses administering medications during the 9 am medication pass time, (P) will implementing a “Quiet Zone” (I) as compared to no intervention (C) reduce interruptions and distractions, decrease medication pass time and improve medication safety (O)
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)
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)
Large portion of medication errors occur during administration
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
NURSING WORKFLOWMedication Administration
Interprets electronic MAR
Verifies Patient Information-Allergies, vitals, labs
Pyxis
Medication Refrigerator
Patient Medication Bin at substation
Obtains necessary supplies from substation: IV tubing, labels, syringes, etc
Verifies medications
obtained with electronic MAR at
computer at substation
Enters patient’s room. Washes
hands
Checks 2 patient identifier and
allergies. Administers medications.
Washes hands
Documents medication
administration at computer
Monitor patient for therapeutic and/or adverse
effects
NURSING WORKFLOW 0854-0926 (32 min)
Medication Administration
Interprets electronic MAR
Verifies Patient Information-Allergies, vitals, labs
Pyxis
Medication Refrigerator
Patient Medication Bin at substation
Obtains necessary supplies from
substation: IV tubing, labels, syringes, etc
Verifies medications obtained with
electronic MAR at computer at substation
Enters patient’s room. Washes hands
Checks 2 patient identifier and
allergies. Administers medications. Washes
hands
Documents medication
administration at computer
Patient Medication Bin at substation
Phone
Call to pharmacy re: missing med
Med. refrigerator
Conversation MD
Find RN for Witness
Pyxis
Patient care
Phone call to MD
MD
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 NursesCognitive Shifts: Shift focus from one
patient to another (Potter et al 2005)
9 shifts/hr=1 shift/6-7 minStacking: cognitive load at any given
time (Potter et al, 2005, Ebright et al 2003)
11 activities at any given moment
NURSING WORKLFLOWStacking and Cognitive Shifts
NURSING WORKFLOW
COGNITIVE SHIFTS
AND
STACKING
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 conditionsActive Failures+ Latent Conditions = Opportunity for Error
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
DATA COLLECTION Developed and validated by Dr Tera Pape
Nurse Distraction Perception Survey
Medication Administration Documentation Observation Sheet
MADOS Tool
QUIET ZONE INTERVENTIONS
Signage Demarcation of Pyxis area
and Sign
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
Do Not Interrupt Nurses During Medication
Administration!Avoid Conversation In This
Area!
QUIET ZONE
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