Research in Nursing & Health, 2013, 36, 116–119

LETTER TO THE EDITOR

Interruptions Are Significantly Associated With the Frequency and Severity ofMedication Administration Errors

The review by Hopkinson and Jennings(Hopkinson & Jennings, 2012) on research ofinterruptions to nurses’ work provides a usefulupdate. We agree with many of the conclusionsin the review, including the need for moreconsistent definitions of interruptions to allowcomparisons between studies and improvedapplication of theory to this area. However webelieve that the authors have been somewhatselective in their presentation of the results fromprevious studies to support their conclusion‘‘that beliefs about the ill effects of interruptionsremain more conjecture than evidence-based.’’An example is the reporting of our 2010 study(Westbrook, Woods, Rob, Dunsmuir, & Day,2010) of interruptions during which weobserved 4,271 medication administrations to720 patients conducted during 505 hours ofdirect observation of 98 nurses at two majorteaching hospitals. This is an analytical cohortstudy to examine a causal association betweeninterruptions and medication administrationerrors. The study was incorrectly defined as adescriptive study in the review. Hopkinson et al.report some of the descriptive results from thisstudy but fail to report the main findings fromthe multivariable analyses using generalizedestimating equations, which we believe provideimportant findings in relation to understandingthe relationship between interruptions and error.

We found that procedural failures (e.g., fail-ing to correctly check a patient’s identification)and clinical errors were both significantly asso-ciated with interruptions. Our modeling showedthat for each interruption procedural failurerates increased by 12.1% and clinical errors in-creased by 12.7%. These associations were in-dependent of hospital, nurse experience, andemployment status. These results are not pre-sented in the review. As we reported from theunivariable analyses, the relationship did not

increase monotonically for clinical errors andHopkinson et al. correctly draw on these resultsto indicate that the relationship between inter-ruptions and errors may not be straightforward.However they are incorrect in the statement‘‘When one or two interruptions occurred, thepercentage of clinical errors was lower thanwhen no interruptions occurred.’’ Examinationof model results and risk of error occurrencereported in Tables 5 and 6 of our original paper(Westbrook, Woods et al., 2010) show thatthis was not the case. This point is incorrectlyre-emphasized in the conclusion of the reviewby Hopkinson et al.

Further, we were surprised to see that theresults demonstrating the relationship betweenseverity of error and interruptions were ignoredin the review. Particularly, as this is a centralmessage of the review, namely that we needto better understand the relationship betweeninterruptions and negative effects. Applyinglogistic regression we were able to estimate therisk of a major medication administration error(i.e., one that is likely to lead to permanentphysical harm to a patient) in the presence ofinterruptions. This showed a significant associa-tion between interruptions and the risk of amajor error. For example, the risk of a majorerror doubled from 2.3% with no interruptionsto 4.7% with four interruptions.

Hopkinson et al. conclude that our findingsare ‘‘inconclusive regarding the precise natureof the relationship between interruptions anderrors. . .’’ However if reported in full, ourresults from this evidence-based analytical studyclearly demonstrate significant relationships be-tween interruptions and errors, and the severityof errors. We agree that understanding theimpact of interruptions on nurses’ work iscomplex and there is much more to understand,but we are concerned that downplaying or

Published online in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/nur.21522

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ignoring existing findings is not helpful inmoving the field forward.

Overall, we congratulate Hopkinson et al.for bringing together research evidence on thisimportant topic, but suggest that the evidencefor potentially significant negative effects ofinterruptions to nurses’ work has been under-emphasized in the review given our researchfindings. Several authors (Coiera, 2012; McGillis,Hall et al., 2010; Rivera-Rodriguez & Karsch,2010), including ourselves (Westbrook, Coiera,et al., 2010; Westbrook, Woods, et al., 2010),have indicated the potential positive role ofinterruptions in keeping patients safe and weagree that further work is necessary to under-stand the positive effects of interruptions.However with over 25% of all interruptions tonurses occurring during medication administration(Kosits & Jones, 2011; Westbrook, Duffield,Li, & Creswick, 2011) there is a clear impetusto focus on this safety critical aspect of nurses’work.

Johanna I. WestbrookDirector Centre for Health Systems &

Safety ResearchAustralian Institute of Health Innovation

University of New South WalesSydney, Australia

Ling LiBiostatistician Research Fellow

Australian Institute of Health InnovationUniversity of New South Wales

Sydney, Australia

References

Coiera, E. (2012). The science of interruption. BMJQuality and Safety, DOI: 10.1136/bmjqs-2012-000783 http://qualitysafety.bmj.com/content/early/2012/03/14/bmjqs-2012-000783.full.pdfþhtml

Hopkinson, S. G., & Jennings, B. M. (2012). Inter-ruptions during nurses’ work: A state-of-the-science review. Research in Nursing & Health,Advance online publication, DOI: 10.1002/nur.21515

Kosits, L., & Jones, K. (2011). Interruptions experi-enced by registered nurses working in the emergen-cy department. Journal of Emergency Nursing,37(2), 3–8.

McGillis Hall, L., Pedersen, C., Hubley, P., Ptack, E.,Heminway, A., Watson, C., & Keatings, M. (2010).Interruptions and pediatric patient safety. Journalof Pediatric Nursing, 25, 165–175.

Rivera-Rodriguez, A., & Karsch, B. (2010). Interrup-tions and distractions in healthcare: Review and re-appraisal. Quality and Safety in Health Care, 19,304–312.

Westbrook, J., Coiera, E., Dunsmuir, W. T. M., Brown,B., Kelk, N., Paoloni, R., & Tran, C. (2010). Theimpact of interruptions on clinical task completion.Quality and Safety in Health Care, 19, 284–289.

Westbrook, J., Duffield, C., Li, L., & Creswick, N.(2011). How much time do nurses have forpatients? A longitudinal study of hospital nurses’patterns of task time distribution and interactionswith other health professionals. BMC Health Ser-vices Research, 11, 319. http://www.biomedcen-tral.com/1472-6963/11/319

Westbrook, J., Woods, A., Rob, M. I., Dunsmuir,W. T. M., & Day, R. (2010). Association of inter-ruptions with increased risk and severity of medi-cation administration errors. Archives of InternalMedicine, 170, 683–690.

Authors’ Response to the Letter toRINAH Editor: Interruptions areSignificantly Associated With the

Frequency and Severity ofMedication Errors

Thank you for the feedback on our state-of-the-science review about interruptions duringnurses’ work (Hopkinson & Jennings, 2012).We share your passion regarding the need tobetter understand the complexities of interrup-tions for the purpose of keeping patients safe.We have great respect for the studies completedby you and your colleagues that expand ourknowledge of interruptions (Westbrook et al.,2011; Westbrook, Duffield, Li, & Crestwick,2011; Westbrook, Woods, Rob, Dunsmuir, &Day, 2010). Our response to your critique

focuses on three concerns you noted regardinghow we characterized findings from the West-brook et al. (2010) study. These are that: (a) theill effects of interruptions remain more conjec-ture than evidence-based and the nature of therelationship between interruptions and errorsremains inconclusive, (b) our statement aboutthe number of interruptions and percent of clini-cal errors is incorrect, and (c) we ignored therelationship between severity of error andinterruptions.

Conjecture is defined as ‘‘an opinion orconclusion formed on the basis of incompleteinformation’’ (Conjecture, n.d.). Of the 31 re-search articles included in our review (Hopkin-son & Jennings, 2012), only one study(Westbrook et al., 2010) provided empirical evi-dence showing an association between

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interruptions during medication administrationand failures or errors. Other studies lacked suffi-cient evidence to support a hypothesized rela-tionship between interruptions and errors(Kalisch & Aebersold, 2010; Potter et al.,2005). The correlational design and statisticaltests used by Westbrook et al. (2010) bear no-tice, yet causality cannot be inferred. In our arti-cle (Hopkinson & Jennings, 2012), we did notmention the lack of established causality; suchverbiage may have clarified what we meant by‘‘the precise relationship’’ (p. 11). Likewise, weused the word ‘‘inconclusive’’ to characterizethe Westbrook et al. (2010) results because al-though associations and relationships wererevealed, the evidence did not illustrate a causallink between interruptions and error rates. Wedo not know if there was something else, anyunobserved or unmeasured variable (e.g., fa-tigue), that might contribute to failures or errors.For instance, fatigue rather than the interrup-tions themselves might be ‘‘causing’’ the errors.As noted by Coiera (2012), the methodologiesused in most studies limit the generalizability ofthe findings and the establishment of causality.We are left with the challenge of exploringthe causal relationship between interruptionsand errors. There are many confounders associ-ated with interruptions that must be betterexplained in future studies.

Second, we are puzzled by the claim thatwe are incorrect in stating that ‘‘When one ortwo interruptions occurred, the percentage ofclinical errors was lower than when no inter-ruptions occurred’’ (Hopkinson & Jennings,2012, p. 10). In our review, we discussed thefindings reported by Westbrook et al. (2010, p.686) that:

The proportion of clinical errors did notincrease monotonically, as for proceduralfailures. . . . For administrations with no inter-ruptions, 25.3% (95% CI, 23.4–27.2%) experi-enced clinical errors. Those with 1 interruptionhad a clinical error rate of 22.5% (95% CI,20.3–24.7%); those with 2, 24.4% (95%CI, 21.1–27.7%); those with 3, 38.9% (95%CI, 31.6–46.1%), and those with 4 or more,30.4% (95% CI, 22.0–38.8%).

It is not our intent to discount the findingsfrom the final statistical model of interruptionsduring medication rounds (Tables 5 and 6 inWestbrook et al., 2010) that showed whencertain nurse and hospital characteristics werecontrolled, there was evidence of an increasedrisk of procedural failure or clinical error witheach interruption per medication round. Again,

although compelling, this evidence did not estab-lish a causal link between interruptions and errorrates.

The final concern focused on the associa-tion between the number of interruptions and anincreased risk for an actual or potential majorerror occurring per medication administration(Westbrook et al., 2010). In retrospect, includ-ing mention of this evidence would have been anice addition to our article and we thank youfor raising the issue. We still maintain, however,that the context surrounding the single act ofinterruption—such as the underlying cause—needs to be further explored.

The results from the Westbrook et al. study(2010) offer beginning empirical evidence foran association between interruptions and errorsduring medication administration activities. Weare concerned, however, that further interven-tions will be implemented to thwart interrup-tions during medication administration withoutfully understanding the implications, includingthat interruptions may be necessary to preventerrors. There may be unintended consequencesof eliminating interruptions during medicationadministration. For example, Anthony, Wiencek,Bauer, Daly, and Anthony (2010) reportedthat reducing interruptions also reduced commu-nication, with reduced communication contrib-uting to situations in which errors may occur(O’Daniel & Rosenstein, 2008). Additionally,medication activities are not bounded by clearmarkers regarding when they begin and whenthey end; rather, medication activities occur acrossall nursing activities (Jennings, Sandelowski, &Mark, 2011). Within the context of nonlinearmedication activities, there is a challenge toidentify and sustain interruptions essential toproviding safe patient care. Evidence from mul-tiple well-designed studies is needed to deter-mine both the negative and positive effects ofinterruptions during all aspects of nurses’ work.Investigators and clinicians need to look beyondminimizing the single act of an interruption tofurther explore the context that contributes tothe initiation of the actual interruption.

We appreciate the interest in our review ar-ticle. The opportunity to comment on how wecharacterized certain findings illustrates theneed to derive a better understanding of thenuances of interruptions. We concur with Coiera(2012, p. 357) that the work by Westbrook andcolleagues is ‘‘robust;’’ we also concur withCoiera (2012) that more work is needed tobetter explain the entirety of the context withinwhich the interruptions occur.

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Research in Nursing & Health

Susan G. HopkinsonLieutenant Colonel, US Army Nurse Corps

Center for Nursing Science and Clinical InquiryLandstuhl Regional Medical Center

Landstuhl, Germany

Bonnie Mowinski JenningsNell Hodgson Woodruff School of Nursing

Emory University, Atlanta, GA

References

Anthony, K., Wiencek, C., Bauer, C., Daly, B., &Anthony, M. K. (2010). No interruptions please.Impact of a no interruption zone on medicationsafety in intensive care units. Critical Care Nurse,30(3), 21–29. DOI: 10.4037/ccn2010473

Coiera, E. (2012). The science of interruption. BMJQuality and Safety, 21, 357–360. DOI: 10.1136/bmjqs-2012-000783

Conjecture. (n.d.). Oxford Dictionaries: Theworld’s most trusted dictionaries. Retrieved fromhttp://oxforddictionaries.com/definition/english/conjecture

Hopkinson, S. G., & Jennings, B. M. (2012). Inter-ruptions during nurses’ work: A state-of-the-science review. Research in Nursing & Health.Advance online publication. DOI: 10.1002/nur/21515

Jennings, B. M., Sandelowski, M., & Mark, B.(2011). The nurse’s medication day. QualitativeHealth Research, 21, 1441–1451. DOI: 10.1177/1049732311411927

Kalisch, B. J., & Aebersold, M. (2010). Interruptionsand multitasking in nursing care. The Joint Com-mission Journal on Quality and Patient Safety, 25,604–612.

O’Daniel, M., & Rosenstein, A. H. (2008). Profes-sional communication and team collaboration. InR. G. Hughes (Ed.), Patient safety and quality:An evidence-based handbook for nurses. (pp. 2-271–2-284). AHRQ Publication No. 08-0043.Rockville, MD: Agency for Healthcare Researchand Quality.

Potter, P., Wolf, L., Boxerman, S., Grayson, D.,Sledge, J., Dunagan, C., & Evanoff, B. (2005).Understanding the cognitive work of nursing in theacute care environment. Journal of Nursing Admin-istration, 35, 327–355.

Westbrook, J., Coiera, E., Dunsmuir, W. T. M.,Brown, B., Kelk, N., Paoloni, R., & Tran, C.(2010). The impact of interruptions on clinical taskcompletion. Quality & Safety in Health Care, 19,284–289. DOI: 10.1136/qshc.s009.039255

Westbrook, J., Duffield, C., Li, L., & Creswick, N.(2011). How much time do nurses have forpatients? A longitudinal study quantifying hospitalnurses’ patterns of task time distribution and inter-actions with health professionals. BMC HealthServices Research, 11, 319. DOI: 10.1186/1472-6963-11-319

Westbrook, J., Woods, A., Rob, M. I., Dunsmuir,W. T. M., & Day, R. (2010). Association of inter-ruptions with increased risk and severity of medi-cation administration errors. Archives of InternalMedicine, 170, 683–690. DOI: 10.1001/archin-ternmed. 2010.65

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