‘Red zones’ help deter distractions, improve safety
When Risk Manager Shawna Willcox, CPHRM, MBA, was investigating the death of a child who mistakenly was administered another patient’s medications at Wyoming Medical Center in Casper, she found that the nurse had been distracted while preparing the morning meds.
“He was interrupted five times while he was pulling the meds and going to the patient’s room,” Willcox says. “The interruptions absolutely were a root cause of him making this error, because he was pulling meds for one patient and the interruptions were about the patient he ended up giving the meds to.”
The red zone program is modeled after rules used in commercial airliners, where flight below 10,000 feet requires a “critical performance mode” in which no conversation is allowed except that necessary for the flight tasks at hand. Willcox and her colleagues realized that the same approach could be used in healthcare, and med passing requires critical performance mode with no distractions.
Red zones were marked on the floor around the automated drug dispensing units in the hospital, and staff were instructed that a nurse in the red zone cannot be interrupted for any reason. The nurse in the red zone is not allowed to converse with anyone outside; for example, nurses cannot chat or even discuss work matters while one is in the zone and the other is waiting her turn to obtain meds. In addition, nurses wear prominent red badge on lanyards from the time they leave the red zone until they have completed dispensing the med to the patient, in the hallways, the patient’s room, and anywhere else the nurse might stop. When the red badge is visible, no one else is allowed to converse with the nurse because he or she should concentrate fully on dispensing the meds correctly.
The red badges are on a lanyard rather than a shirt clip so that when the nurse’s back is to the patient room’s door, the badge can be flipped over to her back to keep it visible. The hospital originally tried using a red towel thrown over the shoulder, but it turned out to be an infection control hazard, plus housekeeping had a hard time keeping the towels red and not turning the rest of the laundry pink.
“The red zones and badges have been a terrific success. We’ve seen a 30% decrease in red zone interruptions since we instituted the system,” Willcox says.
When Risk Manager Shawna Willcox, CPHRM, MBA, was investigating the death of a child who mistakenly was administered another patients medications at Wyoming Medical Center in Casper, she found that the nurse had been distracted while preparing the morning meds.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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