Side Tracks on the Safety Express

Interruptions Lead to Errors and Unfinished… Wait, What Was I Doing?

ISMP Medication Safety Alert 

In This Article


Problem: If you're a health professional, it's hard to get through a single hour of the day without being distracted or interrupted, even when performing critical tasks. For instance, nurses administering medications and pharmacists and technicians dispensing medications are distracted and interrupted as often as once every 2 minutes![1–2] Physicians are interrupted, too—about once every 5 minutes in an academic emergency department (ED) setting and once every 10 minutes in a community ED setting.[3] Multi-tasking is expected from those being interrupted, and constant distractions and interruptions are generally accepted as the norm in healthcare. However, the argument that distractions and interruptions contribute to medication errors is persuasive in the literature. To cite one study, the risk of any medication error increases 12.7% with each interruption, and the risk of a harmful medication error is doubled when nurses are interrupted 4 times during a single drug administration and tripled when interrupted 6 times.[4] Thus, distractions and interruptions have major consequences in healthcare.