I recently heard from Annette Holst, MSN, RN-BC, Education Specialist, Genesis Medical Center, in Davenport, IA ([email protected]). Below, she offers a teaching tool she has affectionately named the Instruction Zone.

A few years back, we started a quality committee called "Safe Medication Administration" that met monthly to look at unusual occurrences [variances] related to medication or medication processes. As we evaluated trends or issues, we wanted to prevent further errors occurring in the future, so we developed a monthly poster that serves as "just in time training." Each month, every unit [35 units with 502 beds] receives a poster to inform everyone of potential process or system errors. We also use this opportunity to teach nurses about new drugs, protocols, and "danger zones" or things to be alert for in medication practices. Staff look forward to their monthly issue, and most units archive all the issues in a notebook for staff to use as a reference. They are also posted on the hospital intranet for staff access. It has been a very successful tool in educating a large number of nursing staff [around 1,000 nurses] in a very affordable, efficient, and effective manner, as well as proactively preventing medication error reoccurrences. We also use this as an opportunity to teach about near misses in patient safety.

Thank you to Annette and her team Tereze Jeffrey, RN, Charge Nurse, Surgical Specialty Unit; Bill Schmidt, PS, RPh, Assistant Manager of Pharmacy; Ann Wester, BA, RN, CPUR, CPHQ, Quality Manager; Sherrie Kopp, RN, CEN, TNS, Patient Safety Officer; Peg Beaudry, Quality Assistant; and all current Safe Medication Committee Members for their hard work and willingness to share their successes. I appreciate it!