Red Zone Medication Safety Initiative in the Cardiac Intensive Care Unit

Purpose:
Reduction of medication errors is a national patient safety goal. Children's Hospital Boston's objective is to decrease the yearly number of medication errors. To accomplish this objective, the Red Zone Medication Safety Initiative was created with the goals of reducing medication errors.

Significance:
Red Zone Principles have been implemented by institutions to reduce medication errors, develop measurable and sustainable practice of medication safety. Nursing studies identified antecedents of medication errors including environment, communication, distractions, RN hours, and level of expertise.

Strategy and Implementation:
Using Six Sigma and Change Acceleration Process frameworks, a baseline assessment of medication events was assessed. Qualitative methods were used to engage staff in the process and collect their perceptions of medication events and possible solutions for averting medication errors. Content analysis was used to organize collected data into domains of current structure, process and logistics of the unit. Strategies were developed and implemented within the Cardiac Intensive Care Unit in the first year: 1. Team identified a common language and script for nurses. 2. Red zone group educated staff nurses, physicians, respiratory therapists, pharmacists, and administrative assistants about the need for distraction free time through letters, posters, and in services. 3. Red zone group created a red zone logo for floor decals, identification cards and posters. 4. Began standardizing all four medication Pyxis'. 5. Created a measurement plan to measure implemented initiatives.

Evaluation:
Conclusions: To Date: Medication errors in 2010 (79) have decreased by 37% when compared to those medication errors recorded in 2009 (124).

Implications for Practice:
Post implementation data on medication errors at this time demonstrate a decrease in medication errors. This initiative exemplifies how direct caregivers were actively engaged in improving patient care.