work interruptions and their contribution to medication administration errors: an evidence review

Evidence Review

Work Interruptions and Their Contributionto Medication Administration Errors:An Evidence Review

Alain D. Biron, RN, Carmen G. Loiselle, RN, PhD, Melanie Lavoie-Tremblay, RN, PhD

ABSTRACTBackground: In many surveys, nurses cite work interruptions as a significant contributor to medication

administration errors.Objectives: To review the evidence on (1) nurses’ interruption rates, (2) characteristics of such work

interruptions, and (3) contribution of work interruptions to medication administration errors.Approach: Search strategy: CINHAL (1982–2008), MEDLINE (1980–2008), EMBASE (1980–2008),

and PSYCINFO (1980–2008) were searched using a combination of keywords and reference lists. Se-lection criteria: Original studies published in English using nurses as participants and for which workinterruption frequencies are reported. Data collection and analysis: Studies were identified and selected bytwo reviewers. Once selected, a single reviewer extracted data and assessed quality based on establishedcriteria. Data on nurses’ work interruption rates were synthesized to produce a pooled estimate.

Results: Twenty-three studies were considered for analysis. A rate of 6.7 work interruptions perhour was obtained, based on 14 studies that reported both an observation time and work interruptionfrequency. Work interruptions are mostly initiated by nurses themselves through face-to-face interactionsand are of short duration. A lower proportion of interruptions resulted from work system failures suchas missing medication. One nonexperimental study documented the contribution of work interruptionsto medication administration errors with evidence of a significant association (p = 0.01) when errorsrelated to time of administration are excluded from the analysis. Conceptual shortcomings were noted ina majority of reviewed studies, which included the absence of theoretical underpinnings and a diversityof definitions of work interruptions.

Conclusions: Future studies should demonstrate improved methodological rigor through a precisedefinition of work interruptions and reliability reporting to document work interruption characteristicsand their potential contribution to medication administration errors, considering the limited evidencefound. Meanwhile, efforts should be made to reduce the number of work interruptions experienced bynurses.

Worldviews on Evidence-Based Nursing 2009; (6)2:70–86. Copyright ©2009 Sigma Theta Tau International

Alain D. Biron, FERASI Fellow, School of Nursing; Carmen G. Loiselle, Director, On-cology Nursing Program, Assistant Professor, School of Nursing; Senior Researcher,Montreal Jewish General Hospital; Melanie Lavoie-Tremblay, Junior 1 FSRQ CareerAward; Assistant Professor, School of Nursing; all at McGill University, Montreal,Quebec, Canada.

Address correspondence to Alain D. Biron, McGill University, School of Nurs-ing, 3506 University Street, Wilson Hall, Montreal, Quebec, Canada, H3A 2A7;[email protected]

Alain Biron wishes to thank the FERASI Centre for Training and Expertise in Nurs-ing Administration Research, Fonds de la recherche en sante du Quebec (FRSQ)doctoral fellowship awards, and Ministere de l’education et des loisirs du Quebecfor their support.

Accepted 28 November 2008Copyright ©2009 Sigma Theta Tau International1545-102X1/09

BACKGROUND

The worldwide incidence of medication administrationerrors varies between 6.6% and 44.6% for all doses ad-

ministered by nurses (Tissot et al. 1999; Barker et al. 2002;van den Bemt et al. 2002; Greengold et al. 2003; Lisby et al.2005). The proportion of these errors with the potential toharm patients, such as permanent disability and death, isestimated at 7% (Flynn et al. 2002). The importance of ad-dressing this problem is recognized internationally (Kohnet al. 2000; Nicklin et al. 2004; World Health Organization2004).

Medication errors are found at every stage of the med-ication use process with one-third of medication errors

70 Second Quarter 2009 �Worldviews on Evidence-Based Nursing

Contribution of Interruptions to Medication Errors

harming patients being associated to the medication ad-ministration stage (Leape et al. 1995). From a medicationsafety perspective, the medication administration stage isdifferent from other stages for two reasons. Nurses actas safeguards against errors intercepting up to 86% of allerrors made by physicians, pharmacists, and others in-volved in providing medications for patients (Leape et al.1995). Second, medication administration has very fewsafeguards against errors because it happens at the end ofthe medication use process (Aspden 2007). For these rea-sons, improvements to the medication administration pro-cess could tremendously maximize medication use safetywithin health care organizations.

Medication errors have been defined as “the failure tocomplete a planned action as it was intended, or when anincorrect plan is used, at any point in the process of provid-ing medications to patients” (Canadian Patient Safety In-stitute 2003, p. 31). Medication administration errors havebeen divided into a number of categories such as wrongtime, unauthorized drug, extra dose, wrong dose, omis-sion, wrong route, and wrong form (Flynn et al. 2002).Wrong time medication administration errors are the mostfrequent comprising 42.8% of all medication administra-tion errors followed by omission with 30.2% (Barker et al.2002). However, wrong time errors are often consideredclinically unimportant, although this perspective has beendebated (Kopp et al. 2006). This incertitude about the clini-cal significance of wrong time errors explains why, at times,researchers studying contributing factors to medicationadministration errors are performing their analysis withand without the wrong time administration error category.

Studies on contributing factors help us to understandthe underlying causes of medication administration errors.Such contribution is urgently needed to assist in the devel-opment of effective prevention strategies (Vincent 2006).In line with this goal, James Reason’s work (Reason 1990)has played a pivotal role in shifting from a person-centeredto a system perspective on potential contributing factors tomedication errors (004). A system approach positsthat, although individuals are responsible for the qualityof their work, more medication administration errors canbe avoided by focusing on the system rather than solelyon individuals. Consequently, if the system approach iscorrect, one of the first steps in a medication administra-tion error reduction program is to systematically documentsystem-related contributors to such errors.

When nurses are surveyed, work interruptions appearamong the most prominent of the system-related factors(Cohen et al. 2003; Balas et al. 2004; Stratton et al. 2004;Armutlu et al. 2008). Work interruptions entail a halt ofthe activity being performed for monitoring purposes or tocarry out a secondary task (Hopp et al. 2005). Distractions,

on the other hand, are detected by a different sensory chan-nel from those of the primary task, and may be ignoredor processed concurrently with the primary task; this isnot the case for work interruptions (Speier et al. 2003).However, both concepts are related. Distractions are thenecessary precursor of work interruptions (McFarlane &Latorella 2002).

A number of hypotheses have been formulated to ex-plain how work interruptions might result in human er-rors. The mechanisms underlying this contribution coulddepend on the task performance level (Reason 1990).Three levels of task performance have been proposed:skill-based, rule-based, and knowledge-based performance(Rasmussen 1986). Skill-based performance is mostly au-tomatic and is found in routine actions. These routine ac-tions require dispersed attentional checks to ensure propertask completion. Work interruptions during skill-basedperformance may interfere with these required attentionalchecks and lead to slips and lapses (Reason 1990). Atthe other end of the spectrum, with knowledge-basedtask performance, nurses must rely on conscious analyt-ical processes and stored knowledge to solve problems.At this level of performance, work interruptions add to theamount of information being processed, and if the demandsfor cognitive resources are higher than those available, taskperformance is negatively affected (Wickens & Hollands2000).

Interventions addressing the frequency of work inter-ruptions in the interests of maximizing medication admin-istration safety certainly represent a promising avenue,considering work interruptions could lead to human er-rors (Potter et al. 2005). However, before intervening, anyevidence on the frequency, characteristics, and potentialcontribution of interruptions to medication administra-tion errors, evidence that goes beyond the data obtainedin the surveys, should be described and assessed system-atically. A thorough review of the evidence is essential toensure that future actions by clinicians, administrators,policy makers, and researchers are informed by the bestavailable information.

OBJECTIVE

To review the evidence on the rates, characteristics, andpotential contribution of work interruptions to medicationadministration errors.

METHODS

This literature review is based on a systematic approachthat includes identification of the studies, their selection,critical appraisal, and data synthesis.

Worldviews on Evidence-Based Nursing �Second Quarter 2009 71


TABLE 1Yield from each database searched

DATABASES COVERAGE YIELD

Embase Ovid 1980–2008, week 6 154Medline Ovid 1980–2008, week 6 138Psychinfo Ovid 1980–2008, week 6 33CINHAL Ebsco 1980–2008, week 6 90Total yield 415All references imported 380

to EndnoteR©

XI.Duplicates removed.

Study IdentificationFour databases were searched for relevant literature onwork interruptions (Table 1). The search strategy used acombination of keywords and medical subject headings(MeSH) terms (Table 2). The MeSH terms were slightlyadapted to each database to reflect their specificities. Key-words were necessary, since work interruptions are notcurrently indexed. “Distraction” was also employed as arelated term. The search strategy involved combining in-terruptions and nursing care, interruptions, and medica-tion administration process-related terms. The final stepof the search strategy involved limiting the results to theEnglish language. Identified references in each databasewere then imported into Endnote R© X1 to remove possibleduplicates. The reference lists of articles meeting inclu-sion and exclusion criteria were also searched for relevantreferences.

Study SelectionThe inclusion criteria were based on study design, par-ticipants, variables reported, and year of publication. Ac-cordingly, published original studies that included nurseparticipants, reported work interruption frequencies, andwere published in English between 1980 and 2008 wereselected for this review. Conference proceedings were ex-

TABLE 2Medline search strategy

CONCEPTS SEARCH CATEGORY SEARCH TERMS

Work interruption MeSH NilKeywords Distraction$, Interrupt$

Nursing care MeSH Task performance and analysis, nursing care, decision making,nursing process, system analysis, time and motion studies

Keywords NilMedication administration process MeSH Medication systems, medication errors, safety management

Keywords Medication$ adj5 administrat$, drug$ adj5 administrat$,Nurses MeSH Nursing staff exp, health personnel, nurses, personnel, hospital.

Keywords Nurs$, personnel$

$ = Truncation function used.

Abstract and title reviewed n=380

Included n=46

Full article retrieved

Excluded n=334

Excluded n=26

Identification from reference list n=5

Included n=20

Analysis performed n=23

Inclusion n=3

Exclusion n=2

Figure 1. Yield from the search and selection strategy.

cluded. The study selection was performed by two re-viewers in a three-step process (primary author AB anda master-prepared research assistant; Higgins & Green2008). Titles and abstracts were first reviewed to iden-tify potential studies for inclusion. The complete articlewas then reviewed to ensure that inclusion and exclusioncriteria were met. The third step involved the identifica-tion of studies from reference lists of studies included foranalysis (see Figure 1).

Data Extraction and AppraisalA standard data extraction form was developed by the pri-mary author and used to extract data from relevant studies,including author, location, objective, design, sample size



and characteristics, sampling method, variables measured,theoretical background, data sources, reliability, validity,interruption definition, statistical analysis performed, find-ings, strength, and weaknesses. Data extracted, when pos-sible, were specific to nursing, and the appraisal criteriawere based on the Cochrane Effective Practice and Or-ganisation of Care Review Group (2002) data collectionfor experimental studies, the Agency for Healthcare Re-search and Quality (AHRQ) criteria for observational re-search (2002), and Mays and Pope (2000) for qualitativeresearch. Data were extracted by a single reviewer (AB).

Data SynthesisA pooled estimate of nurses’ work interruption rate wascalculated by using nurse-specific data from studies re-porting both work interruption frequency and length ofobservation. Further, each study needed to meet a num-ber of quality criteria to be part of this data synthe-sis. Only data from studies measuring multiple sourcesof work interruptions using minimally direct observationwere used. These quality criteria ensured maximum ho-mogeneity of the studies from which data synthesis wasperformed.

RESULTS

The search strategy yielded 415 records. After importationinto Endnote

R©X1, 35 duplicates were removed, leaving

380 records (Table 2). Titles and abstracts reviewed for in-clusion and exclusion criteria led to 46 retrieved articles.The main reasons for exclusion based on reviewed titlesand abstracts are described in Table 3. The full text ofthe retrieved articles was reviewed to ascertain inclusionand exclusion criteria, resulting in 20 included articles.Another five were identified from reference lists; three ofthese five were included, for a total of 23 articles to be crit-ically analyzed (Figure 1). The main reason for exclusionamong retrieved articles was the nonreporting of work in-

TABLE 3Reasons for exclusion based on titles and abstracts

REASONS n %

Not original research 83 24.9Nurses not participants 140 41.9Distraction as an intervention 23 6.9Distraction or interruptions not reported 56 16.8Surveys 15 4.5Conference proceedings 7 2.1Duplicate not identified by Endnote

R©XI 9 2.7

Not published in English 1 0.3Total 334 100

TABLE 4Reasons for exclusion among full retrieved articles

REASONS n %

Not original research 2 7.1Distraction or interruptions not reported 17 60.7Nurses not participants 4 14.3Conference proceedings 2 7.1Other (e.g., methodological) 3 10.7Total 28 100

terruption frequencies (Table 4). The use of the truncatedkeywords, interrupt∗ and distraction∗, resulted in the iden-tification of interrupted time-series studies and of studieson nurses’ use of distraction as a pain management strat-egy. The other category (n = 3) consists of methodologicalarticles whose results appear in studies already included inthe review.

Study CharacteristicsApproximately half of the 23 studies included (n = 12) hadbeen published in the past 3 years. A majority (n = 10) hadoriginated in the United States, followed by the UnitedKingdom (n = 7) and Australia (n = 4). The studieswere typically performed within hospital settings (n = 21)and on different specialty units simultaneously (n = 7).Nonexperimental design studies predominated (n = 14),then quasi-experimental (n = 3), mixed method (n = 3),qualitative (n = 2), and preexperimental (n = 1) designswere comparatively less. Two of the experimental stud-ies specifically targeted “distraction” among nurses dur-ing medication administration (Pape 2003; Pape et al.2005). The first of the remaining two experimental stud-ies documented the impact of a communication interven-tion designed to meet family information needs in theintensive care unit on the number of incoming calls in-terrupting nurses’ work (Medland & Ferrans 1998); thesecond, a change in surgical technology that required lessunplanned and unscheduled interventions from operatingroom nurses (Luketich et al. 2002). Table 5 provides a sum-mary of the main characteristics and findings of reviewedarticles.

Quality AssessmentMost reviewed studies adopted a quantitative approach tothe study of work interruptions (n = 21). Consequently,this section focuses on quality issues specific to quantita-tive studies among which samples’ representativeness andnurses’ work interruption measurements are the most re-current. These limitations should be taken into considera-tion in the subsequent sections.


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Sample RepresentativenessHalf of the quantitative samples included 10 or fewernurses. A convenience sampling strategy, when reported,was used in all quantitative studies except one. Only twostudies (Manias et al. 2002; Tang et al. 2007) providedinformation on the recruitment rate to estimate nursingsample representativeness. Six of nine studies that adoptedan event sampling strategy (as opposed to a time samplingstrategy) did not describe the participants.

Work Interruption MeasurementAnother common limitation of the studies reviewed relatesto the way work interruptions are measured. Distinct def-initions, when present, were used to operationalize workinterruptions. Frequently, the selected definition clearlyinfluenced the actual rates of observed interruptions. Inone study, observations were performed simultaneouslyby two researchers using two different definitions; as a re-sult, the two researchers’ interruption rate estimates aredifferent (5.9 per hour compared to 3.4 per hour; Potteret al. 2005). Others used the terms “work interruptions”and “distractions” interchangeably (Pape 2003).

An additional issue related to quantifying nursing workinterruptions is the number of interruption sources consid-ered. Some authors examined a single source (Medland &Ferrans 1998), whereas others focused on communicationinterruptions, which by definition are initiated by anotherperson (Spencer et al. 2004). Certain authors consideredthe nurses’ patients as a source of interruption (Hedberg &Larsson 2004) while others did not (Pape 2003). As regardsthe definition selected, the number of sources lessened theability to compare results among studies.

Once a definition was selected and the sources carefullyconsidered, data should be reliably collected. Most studiesrelied on direct observation to collect work interruptiondata. Estimates of observer agreement are reported only bySpencer et al. (2004) and Pape (2003), using percentageagreement. The absence of reported reliability estimatesand other preidentified quality issues serves to weaken theinferences that can be drawn from this review. The resultspresented in the upcoming sections should be consideredaccordingly.

Interruption RateBy pooling the data from 14 studies reporting both workinterruption frequency and total length of observation, theinterruption rate is estimated at 6.7 per hour (range 0.8–41.8). This number is based on a total of 2,622 work in-terruptions and 402.5 hours of observation. Furthermore,all 14 studies on which this estimate is based measurework interruptions through direct observation along withthe multiple interruption sources considered. These qual-

ity criteria were selected to maximize the validity of theestimate.

Characteristics of Work InterruptionsInterruptions have been characterized according to in-terruption source, the channel through which the workinterruption is conveyed, the task being performed wheninterrupted (primary task), the requested task by the in-terrupting source (secondary task), duration, and loca-tion. Interestingly, work interruption characteristics areless studied than nurses’ actual rate of work interruptions.The paucity of evidence on work interruption charac-teristics precludes data synthesis, therefore, a descriptiveapproach was used. Unless otherwise specified, the evi-dence presented applies to nursing work in general and isnot specific to medication administration.

SourcesThe sources of work interruptions represent the persons orinanimate objects that initiate them. Two broad categoriesare present among the reviewed studies: individuals (e.g.,health care professionals, patients, family members) andtechnical (e.g., missing equipment, alarms). Some studiesfocused on the individual, others on the technical; othersinclude both categories.

In the individual category, the most frequent source ofinterruption is nursing staff (RNs and assistants), account-ing for 36.5% of all interruptions experienced by nurses(Hedberg & Larsson 2004). Patients initiated fewer in-terruptions compared to other nurses, with reported pro-portions of 24.7% (Hedberg & Larsson 2004) and 26.4%(Lyons et al. 2007), respectively. A considerably lower pro-portion of 4.7% of work interruptions initiated by patientsis also reported (Pape 2003). The latter result is partiallyexplained by the exclusion of patients under nurses’ careas a source of work interruptions.

On the other hand, technical sources of work interrup-tions include alarms originating from inanimate objects(Hedberg & Larsson 2004) and operational failures, thatis, “the inability of the work system to reliably provideinformation, services, and supplies when, where, and towhom needed” (Tucker & Spear 2006, p. 646). A nurseparticipant’s inability to find an intravenous (IV) pump toadminister total parental nutrition (TPN) to a patient isan example of work interruption due to operational failure(Tucker & Spear 2006). The proportion of all work in-terruptions with a technical source varies between 4.5%(Tucker & Spear 2006) and 13% (Hedberg & Larsson2004).

One issue to consider when examining work interrup-tion sources is the erroneous inclusion of the telephone asa source of interruption. The caller and not the telephone



should be considered the source, since it is the caller whoinitiates the phone call; the telephone is simply a com-munications channel. By implication, studies consideringthe telephone as a source of interruptions have generallyunderestimated the frequency of work interruptions initi-ated by other individuals. It is therefore safe to state thata majority of interruptions are initiated by nurses them-selves and other members of the nursing team, althougha nonnegligible number of interruptions have a technicalsource.

ChannelThe channel is the medium through which work interrup-tions are conveyed. Face-to-face interactions, telephones,and pagers are examples of the different channels reportedwhen the interruption source is an individual. Techni-cal channels usually refer to inanimate objects like vitalsigns monitoring devices (Tang et al. 2007). Work inter-ruption channels whose source is an individual have notbeen explicitly reported among studies included in thisreview. However, based on the results of four studies, itcan be deduced that the most important channel to conveywork interruptions is face-to-face interaction (Coiera &Tombs 1998; Coiera et al. 2002; Spencer et al. 2004; Al-varez & Coiera 2005). Work interruptions are, as definedin these four studies, communication events in which asynchronous channel is used. A synchronous channel is“when two parties exchange messages across a commu-nication channel at the same time” (Spencer et al. 2004,p. 270). Face-to-face interactions are the most importantsynchronous communication channel in these studies, rep-resenting at minimum 87% of all communication channelsused (Coiera & Tombs 1998, Coiera et al. 2002, Spenceret al. 2004, Alvarez & Coiera 2005).

Primary TaskThe primary task characteristics describe the activitiesthat nurses are performing when interrupted. Evidenceon primary task characteristics enables a determination ofwhether some nurses’ activities are more at risk of interrup-tion than others. One study provides evidence on primarytask characteristics (Hedberg & Larsson 2004). Most workinterruptions occur during direct patient care (62%) as op-posed to indirect care (32%) (Hedberg & Larsson 2004).Medication administration is the most interrupted nurs-ing activity, with 29% of all work interruptions occurringduring this activity (Hedberg & Larsson 2004). Documen-tation is the next most frequent interrupted nursing activ-ity, representing 14% of all work interruptions (Hedberg& Larsson 2004). Work interruptions among the remain-ing nursing care activities were approximately equally di-vided.

Secondary TaskThe secondary task characteristics describe what the nurseis asked to do when interrupted. The secondary task char-acteristics of interruptions have rarely been quantitativelydescribed, with the exception of Spencer et al. (2004), whoreport that indirect (36%) and direct patient care (28%)constitute the bulk of secondary tasks for nurses with anallocated patient load (Spencer et al. 2004). In support ofthese findings, Hedberg and Larsson (2004) provide a qual-itative description of the main characteristics of secondarytasks. These include exchange of information, instructionsand assistance. They state: “The patient, the relatives ofthe patient and the staff interrupted the nurses when theywanted information from her or when they wanted to in-form the nurse of something they felt was important abouttreatments, examinations or discharge planning” (Hedberg& Larsson 2004, p. 319). Based on these results, indirectpatient management seems to characterize most of the sec-ondary tasks related to interruptions.

DurationDuration refers to the length of the interruption, usuallyexpressed in minutes or seconds. Whereas Spencer et al.(2004) report a mean work interruption duration of 1minute and 22 seconds, Tang et al. (2007) report a meanduration of 45 seconds. From these results, the interrup-tion duration appears relatively short.

Nurses’ Locations When InterruptedLocation describes the physical environment in whichnurses are located when interrupted. Evidence on nurses’locations when interrupted is scarce. The most frequentlocation seems to be the medication room, which ac-counts for 22% of all interruptions (Potter et al. 2005).Some medication rooms, designed as open spaces wherenurses are “at hand,” may promote interruptions (Hedberg& Larsson 2004). The preparation of medication using awall-mounted cupboard in each patient’s room results in64% fewer work interruptions compared to a medicationcart, supporting the argument that open spaces (medica-tion room, hallway) are more prone to work interruptions(Bennett et al. 2006).

In summary, interruptions are characterized as beinginitiated mainly by nurses themselves and other membersof the nursing team, conveyed through face-to-face interac-tions, occurring for patient management purposes, and areof short duration. There is some evidence that medicationadministration is the most interrupted nursing activity, es-pecially in the room where medications are prepared. Asummary table presents studies containing evidence onthe characteristics of interruptions applicable to nurses(Table 6). This table makes explicit that frequency and



TABLE 6Studies reporting characteristics of interruptions

STUDY FREQUENCY SOURCE CHANNEL PRIMARY TASK SECONDARY TASK DURATION LOCATION

Alvarez et al. (2005) X XBennett et al. (2006) XCoiera et al. (2002) X XCoiera et al. (1998) X X XEbright et al. (2003) XFairbanks et al. (2007) XHedberg et al. (2004) X X XLuketich et al. (2002) X XLyons et al. (2007) X XManias et al. (2002) X XMcLean (2006) XPape (2003) XPotter et al. (2005) X XSpencer et al. (2004) X X XTang et al. (2007) X X XTucker and Spear (2006) XWoloshynowych et al. (2007) XTotal 16 7 4 1 1 2 1

sources are the two characteristics most liable to be stud-ied, and demonstrates the dearth of evidence related toother characteristics.

Interruptions as a Contributing Factor to MedicationAdministration ErrorsAmong the literature reviewed, one nonexperimentalquantitative study specifically addresses interruptions asa contributing factor to medication administration errors(Scott-Cawiezell et al. 2007). The overall aim of the studywas to determine the impact of various levels of educa-tional preparation on medication error. Based on a sam-ple of 39 participants (12 RNs, 8 LPNs, and 19 certifiedmedication technician/aides) and using direct observationto collect data on both work interruptions and the rateof medication administration errors, a significant positiveassociation between interruptions and rate of medicationerrors is present when the wrong time category is excluded(p = 0.01). The relationship is also present and significant(p = 0.04) between work interruptions and the rate ofmedication errors when wrong time medication errors areincluded but the relationship is inverse.

Scott-Cawiezell and colleagues (2007) are among thefirst to show quantitative evidence showing interruptionsas a contributing factor to medication administration er-rors. The fact that data were collected using direct ob-servation both for work interruptions and the medicationadministration errors increased the validity and reliabilityof the results. Previous attempts to examine contributors ofmedication administration errors have been almost exclu-

sively based on secondary data analysis of administrativedatabases; this constitutes an important limitation (White& McGillis Hall 2003). Error underreporting partially ex-plains this situation (Wakefield et al. 1999; Flynn et al.2002). On the other hand, information supporting samplerepresentativeness and reliability estimates for interrup-tions and medication administration errors measures areabsent in most studies included in this review. Moreover,no other contributing factors except for educational back-ground were considered. The study was not specifically de-signed to examine the relationship between work interrup-tions and medication administration errors that could po-tentially explain the absence of other contributing factors.

DISCUSSION

The main objective of this review was to identify evidenceon work interruptions, their rate of frequency, character-istics, and contribution to medication administration er-rors, which goes beyond data obtained through surveys.The results of this review are discussed around three mainthemes: the quality of the reviewed studies, the contribu-tion of interruptions to medication administration errors,and possible avenues for interventions aimed at reducingwork interruptions in nursing practice.

Quality of the Reviewed StudiesShortcomings are present at conceptual and methodolog-ical levels among the reviewed studies. From a con-ceptual perspective, the results of this review indicatetwo main problems: the diversity of definitions of work



interruptions, and the absence of a theoretical frameworkon work interruptions and how they potentially contributeto medication administration errors.

Efforts need to be made to better define interruptions.This is a prerequisite to further knowledge development. Inthis review, two main conceptualizations of interruptionsare present. One is task oriented and defined by its ad-herents as “an activity that stops the RN from performingan immediate task” (Potter et al. 2005, p. 332). The al-ternate conceptualization is communication oriented anddefines interruptions as “a communication event in whichthe subject did not initiate the conversation and in whicha synchronous channel was used” (Spencer et al. 2004,p. 270). The choice of either conceptualization is depen-dent, in part, on the objective being pursued.

One could argue that a task-oriented conceptualizationof interruptions might be preferable for two reasons. Atask-based perspective considers all sources of interrup-tions present in the work environment. A communication-oriented conceptualization only considers communicationevents initiated by another individual, leaving aside techni-cal sources of work interruptions such as system glitchesand alarms, which are nonnegligible factors of interrup-tions (Hedberg & Larsson 2004). In addition, a task-basedorientation takes into account the duration of not onlythe communication event (e.g., “Could you please take ablood sample?”), but also the time required to accomplishthe secondary task (taking the sample). Together with thework interruption frequency, the duration of the secondarytask has been hypothesized to have a negative impact ontask performance (Gillie & Broadbent 1989).

Efforts also need to be made to improve the method-ological quality of studies on interruptions. Sample sizeand representativeness as well as how work interruptionsare measured are recurrent issues among quantitative ob-servational studies reviewed, and need to be addressed tomove research forward. Sample size could be increased topromote the external validity of the results and greater at-tention to sample size determination through power anal-ysis would help address this. Participation rates and thecharacteristics of the sample should be provided in addi-tion to sample size justification. Observational studies arevulnerable to selection bias. Providing information on sam-ple and, when possible, population characteristics helps inan evaluation of the extent to which the risk of bias mightbe present (Higgins & Green 2008).

Direct structured observation should be the privilegeddata collection method for interruptions over unstruc-tured observation and self-report. Unstructured observa-tion is less reliable when the objective is to determinenurses’ work interruption frequencies (Bakeman 2000).Self-report, on the other hand, could be considered un-

suitable due to work interruption pervasiveness and fre-quency, rendering nurses’ capacity to recollect their occur-rences limited (Marsch et al. 2005). Reliability estimationis absent in most studies despite interobserver agreementbeing considered a sine qua non condition to observation-based research (Bakeman 2000). Interobserver agreementhelps to evaluate inconsistencies in findings from differ-ent observers who collect basically the same information(Shoukri et al. 2004).

Interobserver agreement is mainly estimated using ei-ther percentage agreement or the kappa statistic. Percent-age agreement is the ratio of the number of occasionsboth observers agree the behavior occurred to the sumof those occasions plus occasions on which they disagreed(Birkimer & Brown 1979). Pape (2003) claimed to haveachieved above 90% reliability, but this result was obtainedbased on the total frequency of distractions and not bydetermining agreement for each distraction occurrences(Baer et al. 2005). Percentage agreement is certainly onepositive step toward better reliability reporting, but per-centage agreement tends to overestimate agreement be-cause it does not account for agreement that would beexpected purely by chance (Sim & Wright 2005). For thisreason, the Kappa statistic should be preferred (Landis &Koch 1977) because a chance-corrected index of agree-ment indicates the proportion of agreement beyond thatexpected by chance.

Contribution of Interruptions to MedicationAdministration ErrorsLimited empirical evidence exists on the contribution ofinterruptions to medication administration errors. Onenonexperimental study examines the potential contribu-tion of interruptions to medication administration errorsand its results are supportive of such contribution (Scott-Cawiezell et al. 2007). Here, the dearth of evidence issimilar to other published reviews on the contributing fac-tors to medication administration errors (Carlton & Blegen2006), which reiterates the need for research in this area.This is particularly important, since the evidence reviewedindicates that medication administration could be at partic-ular risk from work interruptions. The production of newresearch evidence will require more robust methods to ad-equately inform future directions in practice, research, andpolicy.

Reality is complex; interruptions do not take place ina vacuum, but are situated in a context (Brixey et al.2007). Interruptions are one of the potential contribu-tors to medication administration errors. Safety culture(Aspden 2007), nursing leadership (Wong & Cummings2007), the number of hours worked by nurses (Rogers et al.2004), their workload (Tissot et al. 2003), and medication



administration complexity (Scott-Cawiezell et al. 2007)have also been identified as potential contributory factors.The inclusion of these emerging contributing factors in fu-ture studies would enable an estimate of the relative con-tribution of interruptions compared to other contributorsthrough multivariate statistical analysis. This will facilitatethe prioritization of efforts toward reducing the number ofmedication administration errors by prioritizing the great-est contributors. Furthermore, the inclusion of other po-tential contributors will offer evidence on the contextualfactors under which interruptions are most detrimental.

Another potential means of limiting the detrimental ef-fect of interruptions on medication administration is byreducing their frequency. This requires a better under-standing of their characteristics, and thus the need fordescriptive research on interruptions. Evidence on sec-ondary task characteristics that examines the reasons forinterruptions is especially needed. Such evidence will helpdetermine the work interruptions that are avoidable. An-other strategy to minimize the potential detrimental effectof interruptions is to examine how nurses manage them.Different options are available to the interrupted nurse: heor she can execute the secondary task immediately, nego-tiate it, or mediate it through another individual with afiltering function (McFarlane & Latorella 2002). No stud-ies to date report quantitative evidence on the strategiesemployed by nurses to manage work interruptions. Ma-nias et al. (2002) and Hedberg and Larsson (2004) bothidentify the tendency for nurses to immediately respondto work interruptions; a tendency that might not be themost effective way to minimize the detrimental effects ofthese interruptions. Evidence on interruption managementstrategies to maximize medication administration safety isespecially needed, as some work interruptions will remaindespite efforts to reduce them.

Intervening on Work InterruptionsWork interruptions are frequent. This review identified ev-idence that nurses are, on average, interrupted every 9 min-utes, with some evidence supporting a detrimental effecton medication administration practices leading to errors.Efforts to reduce work interruptions due to work systemfailures could certainly be deployed, since they are the-oretically avoidable (Tucker & Spear 2006). An exampleof work system failures applied to medication administra-tion is missing medication, a recurrent problem faced bynurses (Hurley et al. 2007). When a medication is missing,the nurse has to interrupt her medication administrationto locate or to communicate with the pharmacy, and re-member to administer it at a later time.

Some work interruptions initiated by another personcan also be reduced. The intervention described by Pape

(2003) is an example that directly targets distraction dur-ing medication administration. One of these interventionswas for nurses to wear a red vest with the inscription,“Medsafe Nurse, Do Not Disturb,” while administeringmedications. Proactive communication strategies to meetinformation needs of family members in ICU and thus re-duce the number of incoming calls are another example ofhow work interruptions can be minimized. Interventionsshould target work interruptions more than distractions,since the detrimental effect of the former would appear tobe greater than the latter.

Despite any interventions implemented, work inter-ruptions will remain a part of nursing work, due to itsvery nature. Patients’ conditions are constantly changingand adjustments to treatments are consequently required.Members of interprofessional teams need to communicateinformation about patient management, making a certainnumber of work interruptions unavoidable. This situationresults in error-producing conditions, as described by Rea-son’s Human Error Model (Reason 1990), leading to errorsthat could conceivably affect the patient if not interceptedby a defence barrier. Defence barriers as safeguards (e.g.,double-checks) occupy a key role in a system perspec-tive on error prevention. Consequently, it becomes im-portant to implement these defence barriers to maximizepatient safety considering that the work interruptions willlikely remain despite efforts aimed at reducing their occur-rences.

LIMITATIONS

This literature review has some limitations. First, thesearch strategy relied on keywords to identify articles thataddress interruptions, since there are currently no sub-ject headings that apply to this concept in the databasessearched. Keywords used were “interruptions” and “dis-tractions.” It is possible that some papers may have beenmissed due to the decision to retain only these keywords.However, the identification of 415 articles for review, alongwith the search of reference lists of the included articles,makes it less probable that any major studies on nursinginterruptions were missed. Second, data were extracted bya single reviewer. This data extraction process might leadto bias, although results have been discussed extensivelyamong the authors.

IMPLICATIONS

The following implications for research and practice areformulated based on this review of the evidence regardingthe rate of work interruptions in nursing practice, their



characteristics, and their contribution to medication ad-ministration errors.

Further research is needed to better document the con-tribution of work interruptions to medication administra-tion errors, considering the limited evidence found. Fullconsideration should be given to how work interruptionsare embedded in a cluster of factors that best predictmedication administration errors. Future research shoulddemonstrate improved methodological rigor that includesa precise definition of the concept of work interruptions,which translates into a clear operationalization of what is tobe reliably measured. Concurrently, descriptive studies arealso needed to better understand work interruption char-acteristics such as their sources, interrupted primary task,secondary task, duration, and work interruption strategiesemployed by nurses.

A better understanding of work interruption charac-teristics will inform frontline nurses and administratorsto develop effective interventions to reduce the numberof work interruptions experienced by nurses. Meanwhile,two avenues have already been identified from this re-view. Work interruptions resulting from work system fail-ures (e.g., missing medications) represent a prime targetof intervention because they are theoretically avoidable.Another avenue is the implementation of defence barriers(e.g., double-checks) that are critical for the prevention ofmedication administration errors from reaching patients,considering that certain work interruptions may be un-avoidable.

CONCLUSIONS

Evidence so far shows that nurses’ work environment ischaracterized by frequent work interruptions that are ini-tiated mostly by members of the nursing team, that consistmainly of face-to-face interactions, that are mainly for pa-tient management purposes, and that are of short duration.Limited evidence exists on whether these work interrup-tions actually contribute to medication administration er-rors. This observation calls for further studies that willrequire a comprehensive approach through the inclusionof other emerging, key contributing factors to medicationadministration errors. Such evidence is urgently needed todevelop effective prevention strategies.

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