By Steve Harden

Years ago I was invited to help a large teaching hospital revamp their lab processes. The invitation was a result of a horrific mistake that led to hospital staff removing a perfectly good kidney from a healthy patient and leaving a cancerous kidney in a very ill patient. This was, unfortunately, only the worst error in a long series of lab-related mistakes.

The Problem: 

The weak point in their lab process was that every specimen was assigned a tracking number that was completely different from the patient's medical record number. At the end of the lab processes, a single individual in a busy, loud, and chaotic office space had to reconcile the lab tracking number with the patient's medical record number--being careful to match the correct lab results with the correct patient.

Both sets of numbers were printed on an endless continuous-feed computer paper in a very small, difficult-to-read font. It was slow, tedious, laborious work requiring intense concentration over long periods of time. While this cross-match was happening, staff hurried in and out and the phone rang constantly, creating an ever-present din of chit-chat, barked orders, questions, and ringing bells. It was a madhouse.

Pilots who fly long intercontinental routes deal with the same issue. They must program an extended series of letters and numbers into the navigation computer to ensure the airplane flies the correct path to its destination. This is a critical safety task as a navigation error can lead to a deadly mid-air collision. While pilots are entering these waypoints, it is easy to be distracted by an endless stream of visitors to the cockpit. Flight attendants, mechanics, ramp agents, fuelers, and caterers all seem to need the Captain's attention when his focus must be on this critical task.

To ensure safety, many captains make the cockpit a quiet zone when programming and checking the navigation system. No extraneous personnel or conversation are allowed. Pilots know distraction during this phase of cockpit preparation can be deadly.

The Solution: 

At the hospital--drawing from this aviation best-practice--we:

• Sealed off the lab room to cut down on traffic
• Relocated the phones
• Posted bright red and yellow "Quiet Zone" signs everywhere
• And enforced a policy of "sterile communications"--meaning that only conversations related to the task at hand were allowed.

The Results: 

Errors during the cross-matching process ended overnight.

Other hospitals have adopted this same low-cost tactic. In the cardiac intensive care unit at Atlanta's Egleston Children's Hospital, administrators created a quiet- zone to prevent distraction when nurses enter medication orders.

The zone is little more than a computer terminal in a corner of the room behind an orange sign on the floor that reads "Shh ... We're in the MedZone." This safety tool is decidedly low-tech: a quiet place where nurses can place medication orders without being interrupted, even during emergencies.

The zone was created after administrators noticed distracted staff members were making dangerous mistakes when ordering meds.

The deceptively simple system, built on a principle used in aviation, cut medication errors by two-thirds, saving money and lives. The results were so impressive that Dr. Donald Berwick, head of the Centers for Medicaid and Medicare made a personal visit to Egleston to see how it was done.

How about your facility? Where are distraction errors being made--or likely to be made? Have you considered printing a $5 sign and implementing a quiet zone? It will offer a huge return in safety on your small investment of time, effort, and money.

Need A Valuable (but Free!) Consultation?

If you have questions about how and where to implement this safety tool, please email me for a free, no strings attached consultation.