• Work interruptions;
  • patient safety;
  • medication administration errors;
  • nursing care;
  • communication;
  • system analysis


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

Design: A descriptive observational study design was used along with a sample of 102 medication administration rounds. Data were collected on a single medical unit using a unit dose distribution system during fall 2007.

Method: Data collection on WIs relied on direct structured observation. The following WI characteristics were recorded: source, secondary task, location, management strategies, and duration.

Results: 374 WIs were observed over 59 hours 2 minutes of medication administration time (6.3 WI/hr). During the preparation phase, nurse colleagues (n= 36; 29.3%) followed by system failures such as missing medication or equipment (n= 28; 22.8%) were the most frequent source of WIs. Nurses were interrupted during the preparation phase mostly to solve system failures (n= 33; 26.8%) or for care coordination (n= 30; 24.4%). During the administration phase, the most frequent sources of WIs were self-initiation (n= 41; 16.9%) and patients (n= 39; 16.0%). The most frequent secondary task undertaken during the administration phase was direct patient care (n= 105; 43.9%). WIs lasted 1 min 32 s on average, and were mostly handled immediately (n= 357; 98.3%).

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

Clinical Relevance: Interventions to reduce WIs during the medication administration process should target nurses and system failures to maximize medication administration safety.