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Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting
  1. Varuna Prakash1,2,
  2. Christine Koczmara3,
  3. Pamela Savage4,
  4. Katherine Trip5,
  5. Janice Stewart6,
  6. Tara McCurdie2,
  7. Joseph A Cafazzo1,2,
  8. Patricia Trbovich1,7
  1. 1Faculty of Medicine, Institute for Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
  2. 2Healthcare Human Factors, Techna Institute, University Health Network, Toronto, Ontario, Canada
  3. 3Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
  4. 4Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  5. 5Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
  6. 6Odette Cancer Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  7. 7HumanEra, Techna Institute, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Varuna Prakash, Healthcare Human Factors, Techna Institute, University Health Network, 190 Elizabeth Street RFE 4th Floor, Toronto General Hospital, Toronto, Ontario, Canada, M5G 2C4; varuna.prakash{at}


Background Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood.

Objective The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors.

Methods The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment.

Results Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks.

Conclusions Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

  • Interruptions
  • Medication safety
  • Patient safety
  • Quality improvement
  • Simulation

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