This improvement story originally appeared in IHI's 2006 Progress Report.

For the cost of a roll of red tape, the pharmacy at Metropolitan Hospital in Grand Rapids, Michigan, created a simple but effective way to improve medication safety. “The pharmacy is a busy place,” says its Director, Peter Haverkamp, RPh. “Pharmacists often get interrupted as they check a prescription.” So with red tape they created a Safe Zone. “When a pharmacist steps into the Safe Zone to check something, he or she is not interrupted.” When the order is checked, it is passed across the red tape to the “To Go” counter. “No more asking, ‘Is this ready to go?’” says Haverkamp. This simple intervention, along with others implemented in the pharmacy, reduced errors by 40 percent in the first full quarter after they were put into effect.  

In fact, this is just one simple change in a long series of more sophisticated steps that Metropolitan staff members have taken to reduce adverse drug events, something they’ve focused on for many years, as participants in a previous IHI Collaborative on medication safety.

With a culture that supports non-punitive medication error reporting, Metropolitan has effective processes in place to reconcile drugs on admission, improve the safety of narcotic use, eliminate wide-ranging doses, and standardize pain medication orders that eliminate handwriting, a common source of errors.