Reducing Medication Administration Interruptions: A Safety Improvement Tool Kit
Frequent interruptions during medication preparation and administration on a medical-surgical unit increase the risk of dosing, timing, and wrong-patient errors; this tool kit summarizes root causes and an evidence-based plan to reduce them.
Toolkit components
Key Findings
- A near-miss wrong-patient insulin error occurred after a nurse was interrupted twice while preparing medication.
- Root causes span human factors (divided attention, multitasking), environment (medication area next to a high-traffic hallway with no barriers), staffing (minimal backup during rounds), and policy (no formal interruption-management protocol).
- Patient/family needs, fatigue, and workload are established predictors of interruption-related risk during medication administration (Dong et al., 2026).
- Without a just-culture reporting practice, near-misses like this one often go undocumented, limiting organizational learning.
Top Evidence-Based Strategies
- “Stay S.A.F.E.” structured interruption-management training - teaches nurses to stop, evaluate, and redirect focus after a disruption (Schroers et al., 2025).
- Risk-based scheduling - using known predictors of interruptions (e.g., family/patient needs, shift timing) to target support during the highest-risk periods (Dong et al., 2026).
- Just-culture incident reporting - linked to improved staff attitudes and behaviors toward reporting safety incidents (Han et al., 2024).
- Standardized, distraction-free medication administration practices (Tariq et al., 2024).
Safety Improvement Plan
- No-interruption zone around the medication preparation area (signage, vests) - first 2 weeks
- Stay S.A.F.E. interruption-management training via workshop + simulation - within 30 days
- Adjusted day-shift staffing for brief backup coverage during medication rounds - next quarter
- Just-culture near-miss reporting launched - ongoing
- Visual reminders on family/staff communication timing posted near medication carts - ongoing, reinforced in monthly huddles
- Pilot on day shift, then expand to evening/night shifts; reassess at 6 months using incident-report data and a staff interruption survey
Organizational Resources to Leverage
- Patient safety and quality improvement committee (implementation oversight)
- Nursing simulation lab (interruption-management training)
- Pharmacy department (process efficiency review)
- Existing incident-reporting system (near-miss tracking, just-culture data)
- Charge nurses / shift supervisors (daily protocol champions)
Critical Implementation Resources
(Dong et al., 2026) - predictors of nursing interruptions, full text https://pmc.ncbi.nlm.nih.gov/articles/PMC13095847/pdf/JONM-2026-4433675.pdf
(Schroers et al., 2025) - scoping review on interruptions and medication errors, full text - https://acelab.tamu.edu/wp-content/uploads/sites/23/2025/07/Journal-of-Advanced-Nursing-2025-Schroers-Associations-Between-Interruptions-and-Medication-Administration-Errors-2.pdf
(Han et al., 2024) - just culture and incident reporting, full text - https://perpus-utama.poltekkes-malang.ac.id/assets/file/jurnal/oct_2024.pdf
(Tariq et al., 2024) - medication dispensing errors and prevention, full text - https://www.ncbi.nlm.nih.gov/books/NBK519065/
Published by Gabrielle Fuentes RN