Table 4

Comparison of observations during medication rounds pre- and postintervention

Interruption source	Preintervention observations	Postintervention observations
Staff nurses	Staff nurses themselves were the greatest source of interruption	An awareness among nurses of the distracting impact of case-irrelevant conversation was observable. The ‘key holder’ system eliminated the need to interrupt the round to enquire about keys.
Doctors	Doctors interrupted medication administration with non-essential queries	Doctors generally limited interruptions to times when critical information had to be communicated
Personnel	Third largest source of interruptions: staff offered help, initiated personal conversations, sought assistance, requested patient updates	Behaviour changes were evident: personnel were observed approaching the medication trolley, but once alerted by the visual signals, that is the red aprons and alert signs, diverting their query elsewhere
Visitors	Nurses were frequently interrupted at the trolley and in the corridor while en route to collect missing medications	Visitors were alerted by posters and aprons not to disturb nurses. Less noise and fewer staff interruptions created a calmer environment on the round which discouraged visitors from distracting nurses.
Other patients	Of all sources of interruption, this category was the least amenable to control	Efforts to develop a behaviour change among patients were challenged by the unit's rapid patient turnover
Noise	Bay door left open while medication round under way within. High levels of staff traffic and ambient noise within bay during round.	Closing the bay door reduced the ambient noise to much lower levels. Traffic was minimised as staff assessed the need to enter the bay, and where they did so, they were conscious of not disturbing the nurse.
Conversation	Preintervention two nurses had simultaneously administered medications from the one trolley during some rounds	Postintervention, all rounds involved just one nurse working alone at the trolley; therefore this opportunity for interruption was eliminated
Missing medication	A disjointed work pattern was observed during medication rounds: nurses travelled frequently between medication trolleys, centralised care supplies, patient rooms and work stations	Streamlined work practices and teamwork were apparent. Strategies involved: —a second nurse acting as a ‘runner’ to obtain any medications required by their colleague at the trolley. —a single trip to collect all missing medications at the end of the round, rather than leaving the trolley multiple times during the round to locate individual medications.
Telephone calls	Phone calls were one of the most disruptive types of interruptions, requiring the nurse to physically and mentally disengage from the task at hand for possibly several minutes	Of all the categories of interruption, phone calls were the easiest for staff to divert from the nurse undertaking the medication round in that an advance warning of an interruption was issued in the form of the phone ringing
Other	Interruptions mainly related to the nurse abandoning the round to seek missing prescription sheets or equipment—for example, intravenous stands, gloves and tablet crushers	Interruptions were greatly reduced by improved workflow organisation, planning and teamwork
Emergency	There were no patient emergencies which caused interruptions either pre- or postintervention