Holland Bloorview Kids Rehabilitation Hospital is using an innovative approach to avoid bedside medication errors. Red medication sashes are worn by nurses while they prepare and provide medication at patients’ bedsides to visually signal to staff and families to “do not disturb.”
Health Quality Ontario had a chance to catch up with Laura Oxenham Murphy, Interim Director of Quality Safety and Performance, Ana DiMambro, Nursing Clinical Educator, and Nathan Ho, Director of Pharmacy, to learn more about how this initiative is reducing medication errors and improving patient safety.
How did the medication sash initiative first come about?
We know that medication reconciliation (MedRec) is a fundamental step in reducing medication errors and preventing adverse events, however, the actual process of preparing and distributing medications is also an important step and not error proof. Interruptions to the medication administration process have been identified as a leading cause of medication error (Hayes et al, 2015; Medication Errors in Hospitals).
We first pulled data from our electronic tracking system to view medication administration incidents and contributing factors. Our nurse educators then conducted a survey among nursing staff to identify in more depth the top contributing factors. The survey results showed that interruptions and distractions were top factors.
A spaghetti mapping exercise that was also done showed a lot of unnecessary movement was occurring when nurses tried to administer medications. Based on these results, a core group, including the nursing practice council, came up with the creative idea of wearing medication sashes.
Photo above: A nurse wearing a medication sash that says “medication administration” on the front and “do not disturb” on the back. Sashes are washable, can be removed easily, and placed in a nurse’s pocket. Student nurses have access to sashes stored in medication rooms on the units.
How did you implement the sashes?
The sashes were implemented unit by unit. We received feedback from each unit before spreading to other units. We used champions, such as charge nurses and clinical resource leads, to promote the use of sashes among nurses and reiterate the impact on patient safety.
When the sashes were first implemented, existing patients, families and allied health were educated about their purpose and the importance of not disturbing nurses who were wearing them unless it was an urgent matter.
To provide ongoing education, there are white boards on every unit that have photos of nurses wearing the sashes with messaging to indicate why they are used.
What have been the results so far?
The uptake of the sashes has been successful. So far, since implementation, there have not been any medication administration errors specific to interruptions or distractions.
Feedback from families have shown that they are understanding what the sash means and find it comforting that steps are being taken to improve medication safety.
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Do you work on reducing medication errors in your organization? Share your comments and lessons learned by clicking on “Add a Comment” below. You can also connect with Laura Oxenham Murphy, on Quorum.