Keep Away
Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors
Monday July 14, 2008
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Christina Taylor, RN, wears a yellow sash as she prepares to administer medication to her patients.
(Kaiser South San Francisco Medical Center)
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Nurses don the brightly colored garments emblazoned with “Caution: Medication Administration in Progress” to signal to others that they are dispensing medication and should not be distracted. The idea evolved from a quality forum at Kaiser South San Francisco, where front-line nurses, risk management, and patient safety staff, as well as quality improvement personnel, brainstormed on how to improve the medication administration process.
The staff felt it could reduce its already low rate of errors by somehow minimizing interruptions. “We think our error rate is really very good — it's less than one-half of one percent — but we felt that any one medication error is one too many,” Richards says. The staff administers about 22,000 doses of medication each month.
Kaiser incorporated wearing a yellow vest or sash into its standardized medication administration protocol, dubbed KP MedRite. The process requires nurses to don the sash, check the medication administration record using the five “rights” (the right medication at the right time for the right patient at the right dose by the right route), 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.
When first implemented, the flashy attire caused distractions rather than averted them, as curious staff and patients repeatedly interrupted nurses to ask why they were wearing the unusual apparel. And the nurses were not thrilled about wearing the orange construction vests used originally.
“We were going to abandon the pilot, but what we found at the end of 2006 was for that five- to six-month period of time on those two units, we had a 47% decrease in medication errors just from implementing the pilot on those two units,” Richards says.
So Kaiser modified the attire, improved communication throughout the hospital to inform everyone not to interrupt nurses wearing the yellow sash or vest, and implemented the system throughout the hospital in April 2007. (Because of workflow issues in the ED and recovery rooms, the system will not be used in those settings until later this summer.) One other unit declined to participate, citing its minimal error stats. After 30 days, errors had decreased in every unit, averaging a 20% reduction and convincing the reluctant unit — which had no reduction that month — to adopt the protocol and non-interruption wear.
Melody Navarro, RN, MSN, a charge nurse in the med/surg oncology unit at Kaiser West Los Angeles Medical Center, has noticed a culture shift since her facility implemented the KP MedRite process on a pilot basis. She was part of the group of nurses and innovators at the Garfield Center that helped develop the new protocol.
In the past, nurses were routinely interrupted while passing medications. “That's a culture now that we've changed at Kaiser, especially here in our unit,” Navarro says. “We cannot interrupt the nurses now when they pass medication.”
The attire has needed some tweaking there as well. “When we were first starting out [with the sashes], we were looking like beauty queens,” she admits. “The sash was a little too thick and hard to place. Now we've come up with this very thin, bright yellow sash that we wear on a regular basis.”
Patients have been positive about the change, and have been pleased to have the nurse discuss their medications without interruption. Other disciplines now respect the non-interruption wear. Richards adds that some healthcare professionals, such as physicians and pharmacists, are even looking into establishing some non-interruption protocols themselves.
Anne Federwisch is a freelance writer. To comment, e-mail editorCA@nurseweek.com.
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