PATIENT SAFETY: Tips to reduce dangerous interruptions by healthcare staff
Travis “Pete Lewis PhD, RN
Charlene B. Smith PhD, RN
Pamela Williams-Jones MN, RN, WHNP

November 2012 
Volume 42  Number 11
Pages 65 - 67
  PDF Version Available!

INTERRUPTIONS CONTRIBUTE to medication errors, according to The Institute of Medicine's report, To Err Is Human.1 At least 450,000 medication errors occur every year, and annual costs due to these errors are estimated at $3.5 to $29 billion.2The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in medication errors.3 Kliger concludes that "the medication administration process is especially problematic because of the many environmental and workload issues that must be successfully monitored and mitigated during this process."2 According to Westbrook et al., the entire medical, nursing, and administrative team should be held accountable for medication administration error rates.4Interruptions appear to be the norm in healthcare, with studies indicating interruptions make up to 30% of all communications between healthcare providers.5 This article describes the impact of these interruptions on medication administration and practical steps to educate healthcare staff about the dangers of interruptions.Interruptions are defined as uncontrollable and unpredictable stressors that result in information overload and cognitive fatigue.5 All kinds of interruptions occur every day, but when they take place in the clinical environment, the results can be serious or deadly.6 Interruptions have a marked effect on human performance, causing diversion of attention, stress, fatigue, forgetfulness, and error.5Interruptions include those from overhead pages, monitor alarms, rounding by healthcare providers, questions from other nurses, and family inquiries about patients.2 Most patients and family members aren't aware of the many tasks that nurses perform and don't realize they're interrupting or distracting nurses. Healthcare workers may not consider the potential impact of their interruptions on others. Educating them about the hazards of interruptions is as important as educating patients and family members. (To learn how some nurses

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