Research Support

Interruptions to nurses contributed to a staggering 80.2 per cent medication error rate, including clinical errors or procedural failures, according to a study by the University of Sydney's Health Informatics Research and Evaluation Unit. Without interruption, the estimated risk of a major error was just 2.3 %, but with 4 interruptions this risk doubled to 4.7 % (University of Sydney, 2010 study).

Studies show the use of medication interruption vests reduce the number of interruptions by 71% - 74%. Errors in administering medication cause about 400,000 preventable adverse events in hospitals and costs $3.5 billion in a year, according to the Institute of Medicine.

Boytim, J. & Ulrich, B. (2018, January). Factors contributing to perioperative medication errors: A systematic literature review. AORN journal 107(1), 91-107 DOI 10.1002/aorn.12005


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D’Esmond, L. (2016, January). Distracted practice and patient safety: the healthcare team experience: A dissertation. Nursing Forum 52(3). DOI: 10.1111/nuf.12173

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Simmons, D., Graves, K, & Flynn, E. (2009, April). Threading needles in the dark: The effect of the physical work environment on nursing practice. Critical Care Nursing Quarterly, 32(2), 71-74.

AHRQ Innovations Exchange (2003-2018) Checklists with Medication Vest or Sash Reduce Distractions During Medication Administration This process has also reduced medication errors.


Fran, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse, 36(4), 19-35.


Pape, T. M. (2013, July-September). The effect of a five-part intervention to decrease omitted medications. Nursing Forum, 48(3), 211-222.


Pape, T. M. (2011, June). The role of distractions and interruptions in operating room safety. Perioperative Nursing Clinics, 6(2), 101-111.


Pape, T. M. & Dingman, S. D. (2011). Interruptions and distractions during anesthesia induction, Plastic Surgical Nursing Journal, 32(2), 1-8.

Pape, T. M. & Richards, B. (2010). Stop knowledge creep. Nursing Management, 41(2) 8-11.

Prescription for success: Don't bother nurses. (2009) San Francisco Chronicle.

Reducing Distractions is Reducing Medication Errors (2009) by Pat Iyer Medical Legal Support Services.

Reducing Interruptions (2009) And Improving Patient Safety. Lean Blog by Dan Markovitz.

Pape, T. M. (2007, August). First do not distract in The Joint Commission The nurses role in medication safety. 129-150.

Pape T. M. (2006, February). Workaround error. AHRQ WebM&M [serial online].