Article Text

Download PDFPDF
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station
  1. Lacey Colligan1,
  2. Stephanie Guerlain2,
  3. Susan E Steck3,
  4. Tracey R Hoke4
  1. 1Division of Neonatology, University of Virginia Health System, Charlottesville, Virginia, USA
  2. 2Systems and Information Engineering, University of Virginia, Charlottesville, Virginia, USA
  3. 3University of Virginia Health System, Charlottesville, Virginia, USA
  4. 4Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
  1. Correspondence to Dr Lacey Colligan, Division of Neonatology, University of Virginia Health System, P.O. Box 800386, Charlottesville, Virginia 22908, USA; rlc7z{at}


Objective To decrease interruptions around a centrally-located, centralised, open paediatric medication station.

Methods Several established human factors methodologies were used to study paediatric medication administration, including cases with ‘walk through’ and verbal protocols; semi-structured interviews, including critical incident analysis; hierarchical task analysis; and observation.

Results Inexpensive barriers were constructed that protected the tasks likely to lead to errors if interrupted. Meanwhile, sight lines were maintained preserving a family-friendly sense of accessibility of nurses, staff situation awareness and collegiality. Interruptions were significantly reduced and staff attitudes towards the station were significantly improved.

Discussion Targeted barriers may prove useful in other interruptive and chaotic hospital workspaces. They do not require costly training, can be achieved inexpensively and may reduce distractions and interruptions during tasks vulnerable to error. Additionally, the human factors methodologies employed can be applied to other safety improvement projects.

  • Human factors
  • medication safety
  • nurses
  • paediatrics
  • quality improvement
  • patient safety

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This work was generously supported by Grant Number T15LM009462 from the National Library of Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Library of Medicine, or the National Institutes of Health.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Institutional Review Board, University of Virginia.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Specific consent for data sharing was not obtained but the presented data are rendered anonymous and the risk of identification is low. The author may be contacted with requests for data sharing.