Medical-Legal Topics

My father was fascinated by airplanes when I was little. I recall going to Idlewild Airport in New Jersey to watch planes land. My father was trained as an aeronautical engineer. Little did I know as a child the lessons of the airline industry would spread to healthcare and set an example for systems to reduce patient errors. Crew or Cockpit Resource Management is a term that began in 1979 as a way of defining ways to reduce pilot error through better use of the crew. The patient safety movement is now taking lessons from the airline industry. The airline industry has defined the sterile cockpit as a place which controls interruptions during critical moments of flight.

Nurses prepare medications in busy hallways of hospitals and nursing homes. It is easy to interrupt and distract a nurse during the critical steps of preparing medications. Some concerned experts in patient safety suggest the use of a vest to be worn by a nurse during medication administration. The bright orange vest says, “Do not disturb.” I first heard about the use of vest when Gary Sculli, a former pilot turned nurse, spoke to the New Jersey chapter of the American Society of Healthcare Risk Management (ASHRM). I have been an ASHRM member for many years.

Nurses at Kaiser South San Francisco Medical Center ordered bright orange, construction-style vests off the Internet, which the nurses thought looked “cheesy.” They also found them hot and resisted sharing them with fellow nurses. “They felt it was demeaning,” said Becky Richards, RN, BSN, MA, adult clinical services director Richards. But of even greater concern, despite education about not interrupting nurses during med passes, the vests seemed to attract attention. The hospital tried again on a renal floor, with separate medication rooms. But again, it just didn’t seem to click. “We were really thinking about abandoning the whole idea, because the nurses did not like it,” Richards said. But when the medication administration data came in at the end of the year, the hospital found that during the four and five months after the pilot finished, those two units combined had a 47 percent decrease in errors. The units had not done anything else to reduce errors, just the education about no distractions and the vests.

“At that point we knew we could not turn our backs on our patients,” Richards said. The quality forum nurses tweaked the program, finding more attractive neon yellow vests and reaching out to the medical staff, housekeeping and other departments for support. Kaiser South San Francisco kicked off the new program hospital-wide in April 2007, with the exception of oncology, which refused to participate, writing letters and signing a petition. The hospital decided not to play hardball.

“We were blown away in May. The hospital experienced a 20 percent decrease in medication errors, even though one unit refused to participate,” Richards said. “And that was the only unit that experienced an increase from their previous month’s error rate.”
Source: Decreasing Disruptions Reduces Medication Errors – NurseZone

This report verifies the importance of creating a safer environment for preparing medications. Controlling interruptions and eliminating distractions saves lives.

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