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Patient safety, Prevention of medication errors, Quality improvement



  1. Connor, Jean Anne PhD, RN, CPNP, FAAN
  2. Ahern, Jeanne P. MHA, BSN, RN, CCRN
  3. Cuccovia, Barbara MSN, RN, CPON
  4. Porter, Courtney L. MPH
  5. Arnold, Alana PharmD
  6. Dionne, Roger E. PharmD
  7. Hickey, Patricia A. PhD, MBA, RN, FAAN


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.