Interruptions During Medication Rounds: Why They Cause Errors and How to Reduce Them

Every time a nurse is interrupted during a medication round, the chance of an error goes up. Here is why, and what teams can do about it.

Imagine preparing insulin when a relative asks a question, the phone rings and a colleague needs a hand. When you come back, you can’t remember whether you drew up four units or fourteen.

Why interruptions are risky

Research on medication safety has found that interruptions during medication administration are associated with more procedural failures and clinical errors. Each interruption breaks concentration at critical steps.

Common sources

• Phone calls and pagers
• Questions from colleagues, patients and relatives
• Call bells
• Missing medicines or equipment

Ways to reduce them

• Wear a “do not disturb” tabard or apron during rounds
• Explain the system to patients and families
• Have another nurse cover phones and call bells
• Prepare medicines and equipment before the round
• Use quiet zones for preparation
• Pause and restart the check if interrupted

If you are interrupted

1. Stop and finish the step if it is safe, or put things down safely
2. Deal with the urgent issue
3. Restart the checks from the beginning

Frequently asked questions

Do tabards actually work?

They can reduce interruptions when the whole team supports them and patients understand why.

But some interruptions are urgent

Yes, emergencies come first. The aim is to reduce unnecessary interruptions, not ignore real problems.

Related: Medication errors: what to do

Sources: World Health Organization Medication Without Harm, Institute for Safe Medication Practices, published research on interruptions during medication administration (Westbrook and colleagues).