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Interruptions During the Delivery of High-Risk Medications

Trbovich, Patricia PhD; Prakash, Varuna BASc; Stewart, Janice BScN, RN; Trip, Katherine MN, RN; Savage, Pamela MAEd, RN

Journal of Nursing Administration: May 2010 - Volume 40 - Issue 5 - p 211-218
doi: 10.1097/NNA.0b013e3181da4047

Objective: The goal of this study was to assess the nature and frequency of interruptions during medication administration and the interruptions' effects on task efficiency to guide healthcare managers/executives in improving patient safety and staff productivity.

Background: Interruptions have been identified as causal factors in medication administration errors. Research, however, is needed to assess the nature and frequency of interruptions throughout specific stages of the medication administration process and to develop mitigation interventions.

Method: A direct observation study was conducted to document the nature, frequency, and timing of interruptions during specific stages of medication administration in a chemotherapy daycare unit.

Results: Nurses were interrupted, on average, 22% of their time and were frequently interrupted while performing safety-critical tasks. Task completion times were greater for interrupted tasks than for uninterrupted tasks.

Conclusion: Nurses are frequently interrupted during safety-critical stages of medication administration, which decreases task efficiency and could lead to adverse events.

Authors' Affiliations: Research Scientist, Healthcare Human Factors, Centre for Global eHealth Innovation, University Health Network, and Assistant Professor, Institute of Biomaterials and Biomedical Engineering (Dr Trbovich), Clinical Engineering Master's Student, Institute of Biomaterials and Biomedical Engineering (Ms Prakash), Faculty of Medicine, University of Toronto; Clinical Director Inpatient and Outpatient Services (Mrs Stewart), Advanced Practice Nurse (Mrs Trip), Clinical Nurse Specialist (Mrs Savage), Princess Margaret Hospital, Toronto, Ontario, Canada.

Corresponding author: Dr Trbovich, R. Fraser Elliott Building, 4th Floor, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4 (

Funding: This study was supported by a grant from the Canadian Patient Safety Institute.

© 2010 Lippincott Williams & Wilkins, Inc.