QUESTIONS
1. Do you consider interruptions and disruptions as a factor causing
medication error?
2. Throughout your nursing experience, have you ever nearly
committed medication error due to interruption?
3. Do you think these are factors causing interruption during
medication preparation?
a. Question/discussion about other patient
b. Question/discussion from another health care professional
c. Question/discussion about equipment
d. Request for double check for another patient
e. Emergency situation
f. External noise
g. Telephone call
RRL
 An interruption is an attention- getting situation that changes
the course of the task (someone interrupts, medication is
missing). A distraction is an event that attracts the person’s
attention away or interrupts the thought processes (noises,
conversation) or distractions include anything that draws away,
diverts, or disturbs attention from achieving a goal (Pape,
2002).
 Biron et al. (2009) also noted that the risks of medication
administration errors are found to increase by 60 % if a nurse is
interrupted during the preparation phase. They argued that
medication preparation seems a critical step in medication
administration in preventing medication administration errors.
 Hughes & Blegen (2007) found out that factors such as
distractions and interruptions, during the process of delivering
care can have a significant impact on medication safety.
 Pape (2013) explain that the potential for slips and mistakes is
a function of the internal environment, whereas distractions,
interruptions, communication problems, time pressure, and
noise are functions of the external environment.
 Main sources of nurses’ distraction and interruptions are
physicians, other personnel, patients, visitors, telephone calls,
missing medications, emergency situations, conversations, and
external noise (Choo, Johnston & Manias, 2013).
 Fry and Dacey (2007) also found out in their study about the
factors contributory to incidents in medicine administration
that 94% of nurses felt that distractions in the workplace
during medication administration contributed to errors;
interruptions from patients were the most problematic (88%),
followed by answering telephone calls (87%)
h. Alarm/Buzzer from patient
i. Missing medication/prescription
4. Do you find yourself accountable once committed medication error?
5. What do you think are the effects of interruptions during medication
preparation?
a. Medication delay
b. Inaccurate computation of medication dose
c. Wrong medication given to the patient
d. Medication given to the wrong patient
6. When you commit medication error, do you report it to the head
nurse on duty?
7. Do you think a vest that says “Do Not Disturb” will help lessen
medication errors due to interruptions?
 Use of ‘Do Not Disturb’ vests and signage were proposed to
decrease the number of interruptions in the course of
medication preparation and administration (Pape et al, 2005 &
Relihan et al 2010).
 Bundled interventions were also proposed by the researchers
Dall’Oglio, et al. (2016) These interventions included; a
yellow sash with a “Do not Disturb” worn by the medication
nurse on duty, a yellow tape placed in the surrounding floor of
the medication area which means once entered, no interruption
is allowed.
 “Do not Interrupt” bundled interventions were found effective
in reducing medication errors Westbrook (2016)
Intervention comprising vests, ward signs and checklists
significantly decreased the average number of interruptions
per medication round hour from staff nurses, conversation,
missing medications, noise and other causes; but not from
other patients, visitors, doctors and telephone calls (Relihan
eta al,2010