EXECUTIVE SUMMARY

Red lights at nursing workstations can improve patient safety. The lights signal others not to interrupt during critical work.

• No-interruption zones help clinicians avoid errors, particularly with medication.

• The system was implemented with little expense.

• All staff, patients, and family must be educated about what the light means.


Nurses have a lot of responsibilities and must sometimes perform several tasks at once, but there are times when their full attention is needed for a task that is critical to patient safety. One hospital is using red lights on workstations to indicate that the nurse must not be interrupted.

The idea came out of a patient safety committee that focuses on adverse drug events, says Bonnie Seitz, MS, RN, CPN, CNS, pediatric safety officer at Upstate Golisano Children’s Hospital in Syracuse, NY. Staff had seen clinicians at other hospitals using lights on their hospital identification lanyards to indicate that they should not be interrupted, and the idea grew from there.

Organizations including the Institute for Safe Medication Practices and the Agency for Healthcare Research and Quality, as well as other nursing groups, have recommended strategies aimed at increasing clinicians’ focus on tasks particularly vulnerable to mistakes, such as determining medication dosages.

The hospital tried other strategies, including “no interruption” zones in the unit, indicators on lanyards, pins on the uniform, and vests indicating no one should talk to the wearer. When considering the options, Upstate Golisano staff were interested in the idea of a red light on the ceiling that the nurse could activate when preparing medications on a WOW, a workstation on wheels. But that would require going to that space specifically for the task.

“We thought about it more and decided we needed something that would work when we push the med cart into the patient room, because a lot of times the nurses are giving the medications right off the medication cart at the bedside,” Seitz says. “Gone are the days when you had a medication room, where you fixed all your meds up and brought them on a tray to the patient’s room.”

Now, nurses take the meds from a medication dispensing unit, put them on a WOW, and enter the patient’s room to perform the critical medication checks and administer them. The hospital settled on a solution that involved attaching a red light to the WOW, along with a sign that says, “What does the red light mean? Please don’t interrupt me. I need to focus to keep my patients safe.”

Nurses also explain while orienting patients and family to the room that the red light indicates a no-interruption zone.

“We also put signs up in all the charting areas for physicians to tell them, ‘When you see these lights on, don’t interrupt the nurses,’” Seitz says.

Inexpensive to Implement

Upstate Golisano implemented the system in December 2017, paying $425 for the LED lights and Velcro to attach them. The hospital first obtained samples of a few different kinds of lights and took them out on the units to get nurses’ feedback on which ones they liked and how to place them on the carts.

To avoid blinding the user or people nearby, the lights are faced up toward the ceiling.

The red lights are available for all nurses, but about half have not warmed to the idea yet, she says. The reasons Seitz hears from nurses include doubts that anyone will honor the red light and not interrupt, and concerns about looking out of step by using the light when other nurses on the unit don’t.

“I try to push the evidence and impress on them there is lots of proof that this works,” Seitz says. “If we all come on board and use it, this becomes part of our culture that when you see that red light on, that means you don’t interrupt the nurse. If you hold people accountable, it will become embedded and it will become known that that’s how things work in the children’s hospital: A red light means you don’t interrupt.”

The pharmacy director now has adopted the idea, installing red lights in two work areas where he doesn’t want pharmacy technicians interrupted. Respiratory therapists also have expressed interest in placing red lights on their carts.

“Making changes in a busy work environment can be challenging, but we’ve been on this journey since 2009 to change the culture of safety at our hospital,” she says. “Just introducing a good idea doesn’t mean it’s going to catch on immediately, but this one is gaining popularity and we’re not going to let it go because there is so much good evidence for no-interruption zones.”

SOURCE

• Bonnie Seitz, MS, RN, CPN, CNS, Pediatric Safety Officer, Upstate Golisano Children’s Hospital, Syracuse, NY. Phone: (315) 464-5437.