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Running head: IMPLEMENTATION OF QUIET ZONES

Implementation of Quiet Zones to Reduce Medication Errors

Yuliya Moroz

Western Washington University

NURS 402 Translational Research

Christine Espinina, MSN

3/13/17
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Abstract

Background: A leading preventable cause of death in the medical setting is medication errors

(MEs). With nurses working in a busy environment, and being interrupted frequently, this paper

explores the effect of distractions when it comes to MEs. The implementation of quiet zones

(QZs) and the reduction of interruptions may decrease the amount of MEs made in the inpatient

hospital setting.

Purpose/Aim: To assess if the implementation of QZs during a medication pass in the inpatient

setting will decrease the amount/type of MEs made.

Methods: Our literature search began with an individual, general search on CINHAL, Google

Scholar, and PubMed. Individually, we then narrowed down five sources that had the best level

of evidence, adequate sample size, and most relevant to our topic. Validity and strength were the

inclusion criteria. The sources consist of systematic reviews, controlled trials without

randomization, cohort studies, single descriptive, and single quantitative studies.

Findings: The literature research resulted in four main themes around the implementation of

QZs and MEs: MEs are a leading cause of adverse effects, nurses get interrupted frequently,

QZs are beneficial to ME reduction, and creating a culture of awareness is effective for the

reduction of MEs

Implications: Reduction of interruptions through QZs have shown to decrease MEs, indicating

that implementation of QZs can be beneficial. I recommend to implement QZs and increase

awareness of the importance of reducing interruptions to prevent MEs.

Keywords: medication errors, medication administration, interruptions, no interruptions,

distractions, quiet zones, nurses, and nursing.

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Implementation of Quiet Zones to Reduce Medication Errors

Safe and quality care has been the priority and goal of the medical field. Errors have been

shown to have detrimental effects on health economics and humans as reported by, To Err Is

Human: Building a Safer Health System in 1999 by the Institute of Medicine (IOM) (Yoder,

Schadewald, & Dietrich, 2015). A recent study has suggested that medical errors are now not the

eighth leading cause of death in the United States, but the third (Daniels, 2016). Medical errors

are defined by The National Coordinating Council for Medication Error Reporting and

Prevention as,

Any preventable event that may cause or lead to inappropriate medication use or

patient harm while the medication is in the control of the health care

professional, patient, or consumer. Such events may be related to professional

practice, healthcare products, procedures, and systems, including prescribing;

order communication, product labeling, packaging, and nomenclature;

compounding; dispensing; distribution; administration; education; monitoring;

and use (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010, p. 22).

MEs fall under the umbrella of medical errors. MEs can cause adverse patient

outcomes, such as death, and prolong hospital stay. With medication administration being

a nurse-driven task, this places the nurse at the highest risk for making MEs (Smeulers,

Hoekstra, van Dijk, Overkamp, & Vermeulen, 2013).

The causes of MEs have been studied in the inpatient settings, particularly

critical care settings and surgical floors. Findings have shown that the nurses workload,

time of shift, their experience, and any breaks in the system (packaging errors, barcoding

etc.) can be contributing factors to MEs (Smeulers et al. 2013). One factor was the effect
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of interruptions during a medication pass. As shown by numerous studies, an interruption

during any time of a medication pass can increase the risk of an ME to occur (Klejka,

2012). As a new nurse in the busy and hectic intensive care unit, I caught myself

sometimes having difficulty focusing on my medication pass with so many interruptions

distracting me from this critical task. This guided my interest to explore the effect

interruptions can have on patient outcomes and the best way to reduce MEs. The

implementation of quiet zones in the inpatient setting can decrease the number of

interruptions during a medication pass and lessen the possibility of MEs.

Purpose

A team of four students in the BSN program at Western Washington University were

requested by a mentor from PeaceHealth Saint Josephs Medical Center to search the literature

on quiet zones (QZs); the impact they have on decreasing MEs, and the barriers to

implementing QZs. The group did extensive literature research and presented it at a mentor

meeting at PeaceHealth Saint Josephs Medical Center with the goal to potentially implement a

pilot study on one of their inpatient units and assess the outcomes.

Methods

I began the literature search by utilizing search engines such as CINHAL, Medline, and

PubMed. My search began with keywords such as quiet zones OR no interruptions AND

medication errors. My second search was distractions AND medication pass AND

nursing. Further inclusion criteria were peer-reviewed, full text, and published no later than

2010. Articles were excluded if they were not inpatient settings and lower tier evidence. I then

narrowed down my findings to six sources that had the best level of evidence, adequate sample

size, and most relevant to the topic. After I evaluated each of my selected sources, I consulted
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with my team members on the best overall sources from all of our research. We reviewed each

list to identify repeat sources. We then evaluated the validity and strength of each source as a

group to determine what would be included in our final list of sources. Our sources consist of

systematic reviews, controlled trials without randomization, cohort studies, single descriptive,

and single quantitative studies.

Synthesis

Medication Errors

MEs occur frequently and can lead to adverse patient harm (Raban & Westbrook, 2013).

It has been estimated that about $3.5 billion are spent yearly on medical errors and surprisingly it

is an increasing leading cause of death (Yoder et al., 2015). MEs are, any preventable event that

may cause or lead to inappropriate medication use or patient harm while the medication is in the

control of health care professional (Smuelers et al., 2013, p. 18). This impairs safe practice and

reduces optimal patient outcomes. The terrifying aspect of this is that with these high statistics

MEs are also being underreported. It has been found that only two percent of MEs are being

reported (Smeulers et al., 2013). This has led researchers to study what is the cause of MEs and

how to prevent them from occurring.

The IOM was first to suggest that interruptions can be a contributing factor for medical

errors to occur (Smeulers et al., 2013). Since then researchers have found that the nurses busy

workload, their level of experience, time of day, system breaks, and transcriptions can all be

factors to MEs (Anthony et al., 2010). Other factors that can contribute to the causation of MEs

were found to be fatigue, stress, lower nursing education, lacking math skills, and aberration

from hospital policies (such as not barcoding medications, or following provider orders) (Yoder

et al., 2015). With extensive data showing the detrimental effect interruptions have on medical
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errors, researchers have delved in to extensively examine this causative factor.

Nurses are the front-line administers of medication and are the last step before a ME is

committed (Berdot, Roudot, Schramm, Katsahian, Durieux, & Sabatier, 2016). They can use

their critical thinking skills and complex cognitive process to avert MEs from occurring. This

comes to the importance of reducing interruptions for nursing staff during the medication

administration process. Researchers have found through laboratory studies and controlled direct

observational studies, that interruptions were significantly linked to a number of MEs and their

severity (Raban & Westbrook, 2013). Nursing staff when surveyed have reported that

interruptions were the leading cause of MEs to occur (Prakash et al., 2013).

Nurses were found to be more likely commit an ME when completing a multifaceted

activity such a medication pass when interrupted because it affected their line of thinking and

complex reasoning (Flynn, Evanish, Fernald, Hutchinson, & Lefaiver, 2016). Research studies

have shown that interruptions and distractions anytime during a medication pass increased the

risk of adverse MEs (Klejka, 2012). Interruptions can result in a disruption in any of the six

rights of a medication pass; wrong patient, wrong drug, wrong time, incorrect route, and lack of

documentation. One prospective observational study found that 75% of MEs were associated

with multitasking and interruptions in the nurses workflow (Valentin, Schiffinger, Streyrer,

Huber, & Strunk, 2013).

Reviewed observational literature reported that nurses get interrupted on average about

6.7 times per hour (Yoder et al., 2015) and experience about nine cognitive shifts per hour (Flynn

et al., 2016). Also, a mixed methods study revealed that a nurse can get interrupted on average

30 times per shift and errors that occurred were due to inattention, and inability to complete the

task at hand due to the distraction (Anthony et al., 2010). This is because a slip in routine occurs,
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breaking the thought process of complex cognition and problem solving (Yoder et al., 2015).

Slips and lapses in mentation during medication administration accounted for the most common

cause of MEs (Keers, Williams, Cooke, & Ashcroft, 2013).

Interventions to Reduce Medication Errors

Interruptions can occur from individuals such as health care professionals, family

members, patients, and objects such as alarms, phones, and equipment failures (Yoder et. al,

2015). Many studies that implemented or reviewed the Quiet Zone approach referred to the

Sterile Cockpit theory that was implemented in 1981 by the Federal Aviation Authority to

decrease distractions during takeoff and landing (Raban et. al, 2013). The aspects of this concept

include eliminating interruptions, prohibiting communication about anything that that is

unrelated to the task, maximizing teamwork and coordination during this activity (Flynn et al.,

2016). This concept carries over to the inpatient setting to help decrease MEs by implementing

Quiet Zones (QZs) or No Interruption Zones (NIZ). For the purposes of this study, they

will be called QZs.

Various quality improvement projects were implemented in the studies reviewed which

included QZs. A QZ included either red duct tape around the medication cart (Kjelka, 2012) or

flooring with red tile borders (Anthony et al., 2010). This meant while the nurse was pulling

medications out of the Pyxis non-urgent interruptions were not permitted, the nurse's sole focus

was on the critical task at hand. The QZ was clearly marked with signage, the staff were

educated on no distractions or interruptions during medication administration, and in some

studies, the participants wore a sash/bib indicating they were in a middle of a medication pass

(Yoder et al., 2015). The bibs were to indicate other team members, patients, and family

members that a medication pass was in process and not to interrupt the nurse. Various studies
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reviewed for this paper have shown that bibs/sashes were ineffective, causing nurses to forget to

put on the vest and be incompliant. Therefore, this intervention will not be included in this paper.

Staff were also educated how to respond to interruptions by having suggested scripting that

stated Id like to give you my full attention, but I am giving medications right now, and it really

requires my full focus, Could I come to your room (or call or contact you) when I am done in 10

minutes? (Kjelka, 2012, p. 19).

Results

After the implementation of QZs researchers found that interruptions went from 31%

prior to implementation to 18.8% post implementation, having a 40.9% decrease (Anthony et al.

2010). Raban et al. (2013) completed a systemic review of literature and found in four studies

that the implementation of QZs greatly decreased the amount of interruptions made. In one pilot

study, the results showed a decrease in MEs from six errors in six months prior to QZ

implementation, to two errors in six months post implementation (Klejka, 2012).

One systemic review of QZ research literature indicated that after the implementation of

QZs there was 81%-99% increase of uninterrupted time and a decrease in MEs (Flynn et al.,

2016). From the studies systemically reviewed, researchers reported that adverse MEs decreased

60% post implementation of QZs. Finally, after reviewing literature systemically Flynn et al.

(2016) conducted a pilot study on three progressive cardiac care units (PCCUs) implementing

QZ protocols. The project was called Nurses Uninterrupted Passing Medications Safely and

consisted of NUPASS guidelines such as a marked QZs, signage, vests, verbal scripts, and

docking of telephones. After the implementation of interventions, they found the number of

MEs in PCCU1 decreased from eleven percent to three percent and in PCCU2 from two percent

to one percent. The comparison group (PCCU3) also had a decrease in MEs from nine percent to
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one percent (Flynn et al., 2016).

Recommendations/ Implications for Practice

Encourage Culture awareness and Create Quiet Zones

As an ICU nurse, I have encountered interruptions frequently at the Pyxis, in the room

while administering medications, and en route to the room. Thus, one recommendation is to

create a culture change on the units through the education and implementation of QZs. A

common theme shown after the implementation of QZs for medication administration was

nurses stating that they became more aware of the critical task at hand and were less likely of

making an ME. One study assessed the impact of a safety climate in an ICU and found that a

safety climate reduced medical errors (Valentin et al., 2013). Another study has shown that after

the implementation of a QZ protocol nurses stated they had an increased awareness to reduce

distractions and report MEs (Yoder et al, 2015). When debriefed after a study on their ICU unit

nurses reported they had an increased awareness of administrating medications safely and the

need to stay focused (Anthony et al., 2010). Verbal and non-verbal interruptions were shown to

be a significant issue in causing interruptions, therefore, implementing a culture change and

awareness on the unit can lower self-initiated distractions and distractions to others (Smeulers et

al., 2013).

To encourage culture change I recommend hanging QZ posters by medication carts,

educating staff on proper wording to use, hanging posters educating staff/visitors about the

importance of no interruptions and conversations during a medication pass. This will include

educating kitchen staff, housekeeping, physicians, pharmacists, certified nursing assistants,

patients, family members, and whoever else visits the unit. Also, I recommend sectioning off an

area around the Pyxis machine with red tape, which is cost effective and eye catching, to indicate
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a quiet zone. Above the area hang signage that states No interruptions please, medication quiet

zone. Once the nurse enters the patient's room I encourage to empower nurses with a script to

state to patients and family members such as, For your safety [ patients safety] I will ask you to

hold any questions and requests until I am done administering the medication.

Implications for Practice

After reviewing literature, it was found that although extensive studies have shown a

decrease in MEs post implementation of QZs, more research still needs to be completed. There

were several limitations to this study such as underreporting of MEs, difficulty conducting an

unbiased study on the floor, and not enough quantitative research. Thus, I recommend piloting a

QZs project on an inpatient unit at PeaceHealth Saint Josephs Medical Center. This will help

the hospital gather more data on limitations to implementing QZs, barriers, and the outcomes.

Then they can potentially implement a policy change, increase awareness, and promote a culture

change. By implementing QZs patient satisfaction will increase because of the reduction of

MEs and increased safety awareness. Nurse satisfaction will also increase as a nurses can

properly and safely administer medications without the fear of making a mistake when

interrupted.

Conclusion

MEs are costly, occur frequently, can prolong hospital stay, and cost someones life

(Berdot et al., 2016). This literature review focused on MEs, interruptions, and methods to

decrease MEs. After reviewing extensive amounts of peer-reviewed literature it was found that

interruptions are a frequent occurrence in a nurses day, occurring on average 6.9 times per hour

per nurse (Smeulers et al., 2013). With safe medication administration being a nurse-sensitive

outcome (Anthony et. al, 2010) it is crucial to explore methods to decrease MEs. Through the
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implementation of QZs it was found that the rate of interruptions decreased significantly, MEs

decreased, safety awareness increased, and self-reporting of MEs increased to track potential

system errors. QZs included having a designated quiet zone marked with red tape or tile around

medication cart/Pyxis. They also educated staff members, patients, and family members on the

importance of no interruptions during a medication pass. Nurses were encouraged to help staff

members during a medication pass to change the unit culture and promote safety during this

critical task. When implemented on units in observational, experimental, and pilot studies the

results have shown a decrease in the amount of MEs. Thus, the evidence suggests that the

implementation of QZs in the busy inpatient units can significantly decrease the number of

interruptions and MEs made.

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