GM-029 Characteristics of work interruptions during medication administration

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Work interruptions is a significant contributor to medication administration errors.


To document the characteristics of nurses’ work interruptions (WIs) during medication administration.

Material and methods

A descriptive observational study design was used along with a sample of 110 medication administration rounds. Data were collected on 11 medical units using a unit dose distribution system during February 2016. Data collection on WIs relied on direct structured observation. The following WI characteristics were recorded: source, secondary task, location, management strategies and duration.


79 WIs were observed over 25 hours 2 2 min of medication administration time (3.16 WI/hour). During the preparation phase, nurse colleagues (n=22; 27%) followed by system failures such as missing medication or equipment (n=18; 22.8%) were the most frequent source of WIs. Nurses were interrupted during the preparation phase mostly to solve system failures (n=19; 24%) or for care coordination (n=15; 19%). During the administration phase, the most frequent sources of WIs were self-initiation (n=14; 17.7%) and patients (n=20; 25.3%). The most frequent secondary task undertaken during the administration phase was direct patient care (n=45; 56.9%). WIs lasted 2 min 52 s on average, and were mostly handled immediately (n=75; 94.9%).


The process of medication administration is not protected against WIs, which poses significant risks.


Interventions to reduce WIs during the medication administration process should target nurses and system failures to maximise medication administration safety.


No conflict of interest

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