D221 Task 1 SBAR Safety Concern Example

Interruptions During Medication Administration: A Systems-Level Safety Concern on a 32-Bed Medical-Surgical Unit, in SBAR Format

Student Name

Leavitt School of Health, Western Governors University

D221: Organizational Systems and Healthcare Transformation, Task 1

Course Instructor

Month Day, Year

Interruptions During Medication Administration: A Systems-Level Safety Concern on a 32-Bed Medical-Surgical Unit, in SBAR Format

Situation

Nurses on a composite 32-bed adult medical-surgical unit are interrupted repeatedly while preparing and giving medications. During a two-week observation of 40 medication passes by the unit's practice council, 23 passes (58%) were interrupted at least once, most often by phone calls, questions from other staff and call lights, and some passes were interrupted four or five times. This is a systems-level patient safety concern because every patient who receives medications on the unit, about 30 patients on any day shift, is exposed to the same conditions, and because interruptions are built into how the unit's phones, staffing and workflow are arranged rather than caused by any one nurse.

Background

Interruptions during medication administration are a well-documented source of error. In a direct observation study of 98 nurses giving 4,271 medications in two teaching hospitals, each interruption was associated with a 12.7% increase in clinical errors, and the estimated risk of a major error doubled from 2.3% with no interruptions to 4.7% with four (Westbrook et al., 2010). Nurse experience gave no protection. The problem has not gone away with newer technology: a recent observational study of intravenous smart pump use in intensive care units found that 44% of administrations were interrupted by people or phones, and that alarms and alerts took up about a quarter of the time nurses spent on each administration (Vital et al., 2025).

Data Supporting the Need for Change

Locally, the unit's incident reports over the last 12 months record 19 medication events, including two wrong-time doses of insulin and one omitted dose of an anticoagulant. In seven of the 19 reports the nurse wrote that they had been interrupted or distracted. Staff comments at the last practice council meeting described answering the unit phone mid-pass because no clerk is present after 1900, and being approached by providers asking for updates while scanning medications. Together with the 58% interruption rate from the observation audit, these figures show that the conditions linked to error in the literature are present on this unit every shift.

National Patient Safety Standards

The Joint Commission's national patient safety goals for hospitals require organizations to label medications, take extra care with anticoagulants and reconcile medication information accurately (The Joint Commission, 2025). Each of these depends on a nurse completing a series of checks without losing track of where they are. No national standard names interruptions directly, but an interrupted double check or an interrupted scan is exactly where the safeguards these goals require are most likely to fail. Nurses themselves identify interruptions and heavy workloads among the main contextual causes of medication administration errors across 16 qualitative studies (Schroers et al., 2021).

Assessment

The assessment looks at the organizational systems that produce interruptions rather than at individual nurses.

Contributing Systems

Communication systems route every call for a patient to the assigned nurse's phone, whether the caller is a family member, the laboratory or a provider, and the unit has no clerk after 1900 to screen calls. Workflow puts the busiest medication pass at 0900, the same hour as provider rounds, admissions from the emergency department and discharges. Physical space is part of the problem: the medication room is next to the nurses' station, so anyone looking for a nurse walks straight to it. Culture completes the picture. Staff describe an expectation that nurses answer immediately, and no one has permission to decline a question during a pass.

Current Safeguards and Their Limits

The unit already has safeguards that are meant to catch medication errors: barcode scanning of the patient and each medication, an independent double check for insulin infusions and heparin, and pharmacist verification of every order before it appears on the medication administration record. These safeguards work well when a nurse completes them in sequence. They are weakest when a nurse is pulled away between scanning a medication and giving it, or between drawing up a dose and having it checked, because the nurse must then remember where they stopped. Scanning confirms the right drug reached the right patient; it cannot confirm that the dose drawn up after a phone call is the dose the nurse meant to prepare.

The organization has also treated the problem as an individual one. After each of the 19 incident reports, the response was a conversation with the nurse involved and a reminder at the next staff meeting to 'focus during med pass.' No change was made to phone routing, pass timing or the location of the medication room. Schroers et al. (2021) found that nurses across settings describe medication errors as multifactorial and rooted in systems, and that interventions focused on individuals miss the contextual causes nurses report most often. The unit's own response so far fits that pattern.

Stakeholders and Impact

Patients carry the risk of wrong-time, wrong-dose and omitted medications, which is highest for those on insulin, anticoagulants and intravenous antibiotics. Nurses carry the moral weight of errors and the frustration of doing precise work in an environment that keeps breaking their concentration. Providers, pharmacists, unit clerks and the nurse manager are all part of the system: providers generate many of the interruptions, pharmacy calls about order clarifications, and management controls staffing and phone routing. The organization bears the cost of harm, of longer stays and of reportable events.

Recommendation

I recommend a unit-based practice improvement plan to reduce interruptions during medication administration, built on three linked changes: protected time during the 0900 and 2100 medication passes, marked by a visible signal such as a vest or lanyard; rerouting nonurgent calls during those windows to a covering nurse or clerk; and an agreed script for staff to use when they need to pause a question until a pass is complete. The plan should be tested for 90 days, with the observed interruption rate and interruption-related medication events as its measures. The full improvement plan, including roles, teaching and evaluation, follows in the next task.

There is evidence that interruptions can be reduced by changing the environment rather than asking nurses to try harder. In a pre and post intervention pilot in which nurses received training on interruptive communication and wore safety vests during medication preparation and double checks, interruptions during preparation fell from 36.8 to 28.3 per hour and during double checks from 27.5 to 15 per hour (Huckels-Baumgart et al., 2017). The authors recommend that nursing managers treat interruptions as a systems issue, combining staff awareness with physical signals and barriers, which is the approach this recommendation takes.

Conclusion

Interruptions during medication administration on this unit are frequent, linked by strong evidence to errors, and produced by phone routing, workflow timing, physical layout and culture rather than by individual nurses. Because every patient receiving medications is exposed, the problem calls for a systems-level response that protects the few minutes when nurses are doing their most error-sensitive work.

References

Huckels-Baumgart, S., Niederberger, M., Manser, T., Meier, C. R., & Meyer-Massetti, C. (2017). A combined intervention to reduce interruptions during medication preparation and double-checking: A pilot-study evaluating the impact of staff training and safety vests. Journal of Nursing Management, 25(7), 539-548. https://doi.org/10.1111/jonm.12491

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses' perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38-53. https://doi.org/10.1016/j.jcjq.2020.09.010

The Joint Commission. (2025). National patient safety goals effective January 2025 for the hospital program. https://www.jointcommission.org/standards/national-patient-safety-goals/

Vital, C. J., Schroers, G., Fortnam, K., Eckel, S. F., Degnan, D., Armistead, L. T., & Giuliano, K. K. (2025). Evaluation of interruptions during IV smart pump medication administration in intensive care units. Journal of Patient Safety, 22(2), 115-120. https://doi.org/10.1097/PTS.0000000000001427

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690. https://doi.org/10.1001/archinternmed.2010.65