title: Implementing a Distraction-Free Practice With the Red Zone Medication Safety Initiative.
abstract: BACKGROUND
  The incidence of medication errors remains a continued concern across the spectrum of health care. Approaches to averting medication errors and implementing a culture of safety are key areas of focus for most institutions. We describe our experience of implementing a distraction-free medication safety practice across a large free-standing children's hospital.
  
  
  METHODS
  A nurse-led interprofessional group was convened to develop a program-wide quality improvement process for the practice of medication safety. A key driver diagram was developed to guide the Red Zone Medication Safety initiative. Change acceleration process was used to evaluate the implementation and impact of the initiative.
  
  
  RESULTS
  Since implementation in 2010, there has been a significant reduction in medication events of 79.2% (P = .00184) and 65.3% (P = .035) (in the cardiac intensive care unit and acute care cardiac unit, respectively), including months with unprecedented zero reportable medication events. There also has been a sustained decrease in the number of events reaching the patient (33.3% in the cardiac intensive care unit and 57.1% in the acute care cardiac unit).
  
  
  CONCLUSIONS
  The implementation of a distraction-free practice was found to be feasible and effective, demonstrating a sustained decrease in the overall number of medication events, event rate, and number of events reaching patients. This interprofessional approach was successful in a large inpatient cardiovascular program and then effectively transferred across all hospital inpatient units. Additional sites of implementation include other high-risk patient care areas such as procedure/operative units.
authors.affiliation: Jean Anne Connor, PhD, RN, CPNP, FAAN, is director of nursing research for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and clinical instructor of pediatrics at Harvard Medical School. Jeanne P. Ahern, MHA, BSN, RN, CCRN, is staff nurse III, Cardiovascular Operating Room at Boston Children's Hospital, Massachusetts. Barbara Cuccovia, MSN, RN, CPON, is nurse manager for the Hematopoietic Stem Cell Transplant Unit of Boston Children's Hospital. Courtney L. Porter, MPH, is Program Administration Manager II for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital. Alana Arnold, PharmD, is director of the Department of Pharmacy, Boston Children's Hospital. Roger E. Dionne, PharmD, is formulary and medication safety manager for the Department of Pharmacy, Boston Children's Hospital. Patricia A. Hickey, PhD, MBA, RN, FAAN, is vice president and associate chief nurse for Cardiovascular and Critical Care Services, Department of Nursing Patient Services, Boston Children's Hospital, and Assistant Professor of Pediatrics at Harvard Medical School.
authors.forename: Jean Anne
authors.initials: JA
authors.lastname: Connor
authors.forename: Jeanne P
authors.initials: JP
authors.lastname: Ahern
authors.forename: Barbara
authors.initials: B
authors.lastname: Cuccovia
authors.forename: Courtney L
authors.initials: CL
authors.lastname: Porter
authors.forename: Alana
authors.initials: A
authors.lastname: Arnold
authors.forename: Roger E
authors.initials: RE
authors.lastname: Dionne
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Hickey
mesh_terms: D001900:Boston; D064646:Cardiovascular Nursing; D003325:Coronary Care Units; D006776:Hospitals, Pediatric; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D061214:Patient Safety; D015397:Program Evaluation; D011785:Quality Assurance, Health Care; D058996:Quality Improvement