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The No Interruption Zone

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julie radford

on 31 May 2011

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Transcript of The No Interruption Zone

The No Interruption Zone Isolation Procedures For isolation patients,
please take the trays into the rooms with you
and clean off with Sani-wipes upon exiting the room Safety Sash Safety Vest Implementation:
15th of March Why we need this change...
To assist in increasing patient dignity, service, excellence, justice and safety during medication administration What we already have in place:
a no distraction medication room What this adds:

a bright orange medication tray that will serve as a signal to others on the unit to not interrupt Our units were chosen for this project because of the amount of medications that are given on our units

If successful and medication errors are reduced, the orange basket will be implemented house wide Kaiser MedRite Results:
50% reduction in interruptions during medication administration
15% reduction in time spent passing medications
Increase in process reliability from 33% to 78%
The Joint Commission is considering the KP MedRite procedure as a best practice for hospitals across the country.
(Hendrich, Chow, & Goshert, 2009) The idea behind the orange basket is to use it to carry prepared medications from the medication room to the patient's room

While the basket is being carried, potential interrupters will see its use and take time to consider the urgency of their interruption

OVERTIME, THE BASKETS WILL COME TO SERVE AS A SYMBOL OF COMMITTMENT TO PATIENT SAFETY By Julie Radford, RN, BFA The Orange Tray:
A Symbol of Service and
Commitment to Patient Safety The 5 Rights of Medication Administration Patient and Family Education Are the "5 rights" enough? Right patient, medication,
route, dose, and time The right reason and documentation recently added (Conrad, Fields, McNamara, Cone, & Atkins, 2010) Is this enough? Evidenced Based Research Shows: To decrease the amount of medication errors,
the"5 rights" were created 1.5 million avoidable medication errors that injure patients every year
7,000 deaths from medication errors every year
Only 2% of errors are currently caught BEFORE administration

(IOM, 2006, 1999; Leape, 1995) Nurses need to pay closer attention to the medications they are administering to fulfill their responsibility to their patients
We are the last stop before medication is given and this stop must be protected from interruptions
Studies have shown that interruptions during medication administration is a major problem for ICU nurses ...are directly linked to increased errors in administration and decreases patient safety (even with seasoned nurses)
...promote ineffective care delivery
...creates conflicts and stress within the healthcare team
...increases the cognitive burden of interuptee, weakening focus on complex jobs
...create adverse outcomes and events
...increase medication administration time

(Brixey, Robinson, Tang, et al., 2005; Potter, Wolfe, Boxerman, et al., 2005) Interruptions... But Interruptions Are Part of What Being A Nurse, Especially An ICU Nurse, Means! "Nurses and other healthcare professionals must challenge one another to pause and consider when it might be unacceptable and even inappropriate to interrupt a nurse. We must identify interruptions that are expected, normal or even appropriate versus interruptions that distract us from promoting safe patient care"

Dave Hanson (The Joint Commission Perspectives on Patient Safety, 2010) Recent study on medication errors and interruptions Observed 98 RN's preparing and administering meds
53.1% of the time, interruptions occurred
EACH interruption related to 12.1% increase in procedural failures and 12.7% increase in clinical errors
Increase in interruptions positively related to increased medication errors
Also found that nursing experience provided NO protection against making a clinical error and was, in fact, associated with higher procedural failure rates

(Westbrook, Woods, Rob, Dunsmir, & Day, 2010) How familiar is this situation to you? Interventions Being Used to Decrease Medication Interruptions Negative Aspects of These Interventions Nurses do not like the aesthetic look of these interventions: beauty queen or construction worker
Infection control becomes an issue between nurses St. Joseph Hospital
MICU and SICU
Pilot Intervention Based around the principles of Kaiser's MedRite Program, but instead of a vest or sash, we will be using orange medication baskets How do I tell people to not interrupt me without being rude? Learn to say "no" to protect ourselves and our patients Nurses need to role model these behaviors for interventions to be successful Partner with your families and educate them on the dangers that exist when nurses are interrupted during high-risk tasks
Emphasize that non-emergency interruptions can have a negative impact on their loved ones outcome
Share results of EBP studies which relate interruptions to medication error
Educate them on the meaning behind the orange basket and refer them to posted signs that will be placed in the patient’s room Consider yourself as an airline pilot...
We take great comfort in knowing that prior to boarding an airplane, the pilot has been uninterrupted while adjusting and testing the aircraft for safety as mandated by the FAA. This rule is called the "sterile cockpit rule." The rule prohibits activities such as eating meals, having nonessential conversations, or reading anything which is not related to the current flight. All to ensure you and your family's safety (Hohenhaus, 2008).

How would you feel about boarding an aircraft in which the pilot did not follow these rules? It can be as simple as, "I would like to be able to give you my full attention, however, I am giving medications right now and it really requires my full focus-could you call back in 10 minutes?"
(Conrad, McNamara & Atkins, 2010) Or it can be more in-depth as Ury (2007) recommends:
1. Identify similar interests and shared values as the person interrupting you. Example: "I know that we both agree that patient's safety is the most important aspect of our job."
2. Acknowledge their needs and use the word "no" within the context of the previous step.
Example: "I recognize you're asking for help, but what I am doing requires my full attention. If distracted, I might lose sight of patient safety and may harm a patient."
3. Finish with a "yes."
Example: "Even though I can't help you right now, I will be more than willing to help you in a few minutes." What about the right to focus? Kaiser MedRite Process: The process requires nurses to don the sash, check the medication administration record using the five “rights,” wash their hands, get the proper medication, turn down the TV or radio in the patient's room, turn up the lights, double-check the patient's identity, discuss the medications with the patient, administer the medication, document the delivery, and wash their hands again before removing the sash (Hendrich, Chow, & Goshert, 2009) After implementation of a program (which included special med room, minimum distractions, following the 7 rights, and educating the unit on the culture change), one study found:
Interruptions dropped from four interruptions to one per administration
Time of medication administration decreased from 15 to 10 minutes
Medication errors decreased by 22% the first year and 53% by the end of the third year
(Conrad, Fields, McNamara, Cone, & Atkins, 2010) Another study found that visible signs combined with the 6 rights and written standard protocols helped to reduce the medication error rate in just three weeks
(Pape, Guerra, Mazquiz, Bryant, Ingram, Schranner, Alcala, Sharp, Bishop, Carreno, & Welker, 2005) Surveyed staff on distractions, created "no talk" signage for floor in front of Pyxis and reduced yearly medication error rates from 23 to 5
(Briefings on Patient Safety, 2008) It is imperative to reduce distractions on a critical care unit because critical care nurses work with many potent medications which can also greatly harm the patient if not given correctly

(Kane-Gill & Weber, 2006; Rothschild, Landrigan & Cronin, 2005; Valentin, Capuzzo, Guidet, et al., 2006) Medical errors created by performance failures in an ICU were found to be related to failure or inattention to finish an intended action in patient's care

(Rothschild, Landrigan, Cronin, et al., 2005) Klieger (2009) assisted in conducting study in which a safety bundle was implemented on six various size hospitals. The safety bundle consisted of:
the 6 rights
keeping medication labeled until at the bedside
a hospital wide "quiet time" for main medication passing hours with overhead announcement at the beginning and end of the hour.
Results included:
A 50% improvement with medication administration accuracy rate within six months Wagner, Pasko, Glenn, Lapinski, Callow & Shaw, 2010, found that having pharmacy technicians deliver medications directly to the patient's bedside decreased missing medication interruptions by 85% Stream lining the medication administration process:
make sure all necessary supplies are at medication cart prior to beginning (including all medications)
inform other nurses that you will be beginning medication rounds
inform nursing students to hold off all questions until after the orange baskets are empty and taken out of the patient's room
avoid starting extraneous unrelated conversations
if interrupted unnecessarily, refer question to a colleague who is available
(Adapted from Relihan, O'Brien, O'Hara & Silke, 2010) References

Anthony, K., Wiencek, C., Bauer, C., Daly, B., & Anthony, M. K. (2010). No interruptions please: Impact of no interruption zone of medication safety in intensive care units. Critical Care Nurse, 30(3), 21-29. doi: 10.4037/ccn2010473

Brixey, J. (2010, March/April). Interruptions in workflow for RN’s in a level one trauma center. Patient Safety & Quality Healthcare, 24.

Conrad, C., Fields, W., McNamara, T., Cone, M., & Atkins, P. (2010). Medication room madness: Calming the chaos. Journal of Nursing Care Quality, 25(2), 137-144. doi: 10.1097/NCQ.0b013e3181c3695d

Facility implements ‘no-talk zone’ to cut down on medication errors. (2008, February). Briefings on Patient Safety, 9(2), 10.

Hendrich, A., Chow, M. P., & Goshert, W. S. (2009). A proclamation for change: Transforming the hospital patient care environment. Journal of Nursing Administration, 39(6), 266-275.

Hohenhaus, S. M., & Powell, S. M. (2008). Distractions and interruptions: Development of a healthcare sterile cockpit. Newborn and Infant Nursing Reviews, 8(2), 108-110. doi: 10.1053/j.nainr.2008.03.012



Institute of Medicine. (1999). To err is human: Building a safer health system (1st ed.). Washington, D.C.: National Academies Press.

Institute of Medicine. (2006). Preventing medication errors. Retrieved from http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx

Kleiger, J., Blegen, M. A., Gootee, D., & O’Neil, E. (2009). Empowering frontline nurses: A structured intervention enables nurses to improve medication administration accuracy. The Joint Commission Journal on Quality and Patient Safety, 35(12), 604-612.

Lame-Gill, S., & Weber, R. (2006). Principles and practices of medication safety in the ICU. Critical Care Clinics, 22(2), 273-290.

Leape, L., Bates, D., Cullen, D. (1995). Systems analysis of adverse drug events. Journal of the American Medical Association, 274(1), 35-43. doi: 10.1001/jama.1995.03530010049034

Pape, T. M., Guerra, D. M., Muzquiz, M., Bryant, J. B., Ingram, M., Schranner, B., . . .Welker, J. (2005). Innovative approaches to reducing nurses’ distractions during medication administration. Journal of Continuing Education in Nursing, 36(3), 108-116.

Potter, P. (2010, March/April). The impact of interruptions on the cognitive work of nursing. Patient Safety & Quality Healthcare, 24.
Relihan, E., O’Brien, V., O’Hara, S., & Silke, B. (2010, May). The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration [online]. British Medical Journal Quality and Safety. doi: 10.1136/qshc.2009.036871

Rothschild, J. M., Landrigan, C. P., Cronin, J. W., Kaushal, R., Lockley, S. W., Burdick, E., . . .
Bates, D. W. (2005). The critical care safety study: The incidence and nature of adverse events and serious medication errors in intensive care. Critical Care Medicine, 33(8), 1694-1700. doi: 10.1097/01.CCM.0000171609.91035.BD

Ury, W. (2007). The power of a positive no. New York, NY: Bantam Dell.

Valentin, A., Capuzzo, M, Guidet, B., Moreno, R. P., Dulanski, L., Bauer, P., & Metnitz, P. (2006). Patient safety in intensive care: results from the multinational sentinel events evaluation study. Intensive Care Medicine, 32(10), 1591-1598. doi: 10.1007/s00134-006-0290-7

Wagner, D., Pusko, D., Glenn, D., Lapinski, J., Callow, L., & Shaw, B. (2010). The medication manager: Results of a medication at the bedside pilot in a pediatric teaching institution. Journal of Patient Safety, 6(2), 76-79.

Westbrook, J. L., Woods, A., Rob, M. I., Dunsmir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. Additionally, one of these posters will be hanging next to the television for patient education
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