In an age where mobile apps, big data and sophisticated technology seem to dominate every conversation about health care innovation, Jamie Harris’s quality improvement project might not seem so revolutionary. But Harris, a nurse in the cardiac electrophysiology program at Boston Children’s Hospital, saw an opportunity to take an existing patient safety initiative and use it in a new way.
Harris was familiar with the hospital’s Red Zone Medication Safety Initiative from her time working as an inpatient nurse at Boston Children’s.
The Red Zone program, led by Jean Connor, PhD, and Patricia Hickey, PhD, is an ongoing and highly successful effort to reduce medication errors by empowering clinicians, enhancing communication and teamwork, and reducing interruptions and distractions. When nurses give medication to any patient on a floor at Boston Children’s, they do so in a distraction-free environment called the “Red Zone.” This designated area serves to remind others that allowing nurses to fully concentrate on their task can eliminate errors.
Nurses all over the hospital learn and incorporate Red Zone principles into their daily practice, and signs on the inpatient floors serve as visual reminders.
“But when patients are discharged,” says Harris, “parents are suddenly responsible for administering medications — many of them high-risk drugs — and they’re doing it in their own homes, where distractions are all around.”
Harris saw an opportunity to educate parents on the Red Zone principles during discharge to prepare them for administering medication to their children at home.
Harris convened an interdisciplinary team to bring Red Zone principles to patients discharged after hospitalization for a heart rhythm problem. They created physical toolkits for parents to take home with their children after a stay on the cardiac floor.
The kit opens up like a toolbox, with a sign on the top bearing the Red Zone logo. By displaying the logo and setting up the items from the kit, caregivers can quickly designate any area as a “distraction-free zone.” Inside the box are drug safety sheets with important information on each medication, which parents can hang in their home just like the visual checkpoints in the inpatient units.
The kit also includes a flipbook of laminated notecards with key concepts, such as how to describe the Red Zone objective to family members.
“We intentionally didn’t make anything a handout,” says Harris. “We wanted everything about the kit to be tactile and appeal to all different learning styles.”
Pilot project and early feedback
The Red Zone at Home team:
The “Red Zone at Home” team is following a group of ten patients (nine have been enrolled so far) to collect feedback on the intervention.
The patients in this pilot group are all on liquid oral anti-arrhythmic medications (flecainide, sotalol, amiodarone) that act directly on the heart’s electrical conduction system. Proper dosage is therefore extremely important.
Harris interviews parents in the project by phone 48 to 96 hours after discharge. “We’ve had great feedback so far,” she says. “Parents really like the physical space of the Red Zone and the fact that they can re-create that space at home. They also like the focus on language; the emphasis on being ‘distraction-free.’ They like having the key concepts on the notecards.”
Designed with parents in mind
Red Zone data collected and evaluated on the inpatient floors show the number of near-misses — times staff came close to making a medication error, but a double-check prevented the problem. The data feed into each unit’s quality improvement program so staff can learn from them.
“There’s nothing analogous to this in the home,” says Harris. “We document what we can, but it’s all self-reported. And you can’t self-report if you’re not aware an error was made.”
Adverse events happen for a number of reasons. Some of the most common contributing factors at home are:
• confusion about the medication schedules
• two caregivers duplicating a dose
• caregivers using the wrong syringe size, or mixing up two different medications.
Factors like language barriers, financial barriers to medication refills and transitioning patients between multiple households can also impact the safe administration of medications at home. All of these need to be considered and, Harris hopes, addressed by The Red Zone at Home.
Harris says a future goal is getting the kit translated into multiple languages. The kits can also be adapted for use beyond patients seen at the Heart Center.
“It doesn’t always take a high-tech innovation to make a positive impact on patient outcomes,” she says.
Sometimes, it just takes a passionate nurse, a bold idea, a supportive work group and craft supplies.
Jamie Harris is a Staff Nurse II in the Electrophysiology Division of Cardiology at Boston Children’s Hospital. She provides nursing care to children and adults with congenital heart disease, arrhythmia, and cardiac rhythm management devices across the outpatient, inpatient, and procedural settings.