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WEB EXCLUSIVE: Keep Away

Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors

Monday August 25, 2008
<B>Christina Taylor, RN, wears a yellow sash as she prepares to administer medication to her patients.</B>
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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Adult Clinical Services Director Becky Richards, RN, BSN, MA, did not intend to spawn a fashion revolution when she first began searching the internet in 2006 for brightly colored vests for her staff at Kaiser South San Francisco Medical Center to wear while dispensing medication. But with the impressive effect the “non-interruption” wear has had on reducing medication administration errors and the time dispensing meds, yellow sashes and vests just may become as common accouterments to modern nurses' attire as caps were a century ago.

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.

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Anne Federwisch is a freelance writer. To comment, e-mail editorCA@nurseweek.com.