Distractions and interruptions are common in healthcare settings and pose a significant threat to human performance and patient safety, particularly during medication-related tasks. A distraction occurs when attention is diverted from a primary task, while an interruption occurs when a task is stopped to address another activity with the intention of returning later. In modern practice environments, multitasking is often expected, and pharmacists, technicians, and nurses may be distracted or interrupted as frequently as every two minutes. Sources of distractions may be voluntary, such as multitasking, checking emails or mobile devices, and socializing, or involuntary, such as hunger, fatigue, or stress. Interruptions are typically external and include phone calls, patient questions, conversations among colleagues, electronic health record alerts, and device alarms. These disruptions can impair concentration, increase cognitive load, contribute to forgetfulness, and lead to medication errors. A retrospective analysis of patient safety reports found that nurses were most frequently interrupted, followed by technicians and pharmacists, with interruptions commonly related to environmental factors such as high workload or by other individuals. These interruptions contributed to errors including wrong dose, wrong medication, omissions, and medication mislabeling. While some interruptions are necessary to communicate urgent safety information, unnecessary disruptions during critical tasks can adversely affect care quality, practitioner well-being, and patient outcomes. [1]
To reduce distractions and interruptions, organizations should implement comprehensive system-based strategies focused on protecting critical tasks and improving workflow. High-risk activities such as medication order entry, verification, preparation, dispensing, smart pump programming, automated dispensing cabinet access, and medication administration should be designated as interruption-limited tasks requiring dedicated focus. Work environments should be optimized by reducing unnecessary noise, minimizing overhead paging, improving lighting, locating medication preparation areas and dispensing cabinets away from high-traffic zones, and supplying ready-to-administer medications when possible. Communication processes should be redesigned to reduce avoidable interruptions through asynchronous electronic messaging, triaged phone systems, and designated staff to screen non-urgent calls. Alert fatigue should be addressed by limiting nonessential electronic alerts and overly sensitive alarms so that critical warnings retain importance. Staff should be encouraged to prepare workspaces in advance with all necessary supplies and to use checklists or guided technologies for lengthy or complex tasks so work can be safely resumed after interruptions. Teams should establish designated times for non-urgent questions and, when urgent communication is necessary, deliver it during natural transitions between subtasks whenever possible. Policies governing mobile device use should minimize personal-device distractions, and staff education should reinforce the risks of interrupting colleagues during critical tasks. Simulation training that incorporates distractions can improve awareness and resilience, while structured bedside rounds and proactive patient communication can reduce interruptions from patient or caregiver questions during medication administration. [1]
In a 2026 article, strategies were explored to minimize distractions and interruptions within a pharmacy setting, focusing on enhancing the workflow of pharmacy technicians. The article identified that pharmacy technicians face numerous interruptions, averaging 10 distractions per hour, as compared to 15 for pharmacists in a 500-bed teaching hospital. This frequent rate of interruptions, observed every four minutes, significantly increases the risk of medication errors, with existing research suggesting that 75% of medication errors are due to distractions, raising the error risk by nearly 13% with each interruption. To address this issue, the article provided eight practical strategies geared towards improving concentration and efficiency. Recommendations included completing one task before starting another to ensure accuracy and customer satisfaction, designating specific duties to team members to reduce multitasking fatigue, and establishing no-interruption zones for tasks requiring high concentration. Furthermore, maintaining notes to track task progress when interrupted, triaging tasks based on urgency, and limiting the use of personal electronics were emphasized. The article also advised muting non-essential alerts and encouraged technicians to communicate workflow improvement ideas to management, underscoring the essential role of technician feedback in implementing effective changes within pharmacy operations. [2]
According to a 2016 article, interruptions and distractions (I&Ds) are frequent in hospital pharmacy settings and adversely affect workflow efficiency, concentration, and medication safety. Multiple observational studies found pharmacists and technicians experience frequent disruptions, ranging from approximately one every 6 minutes to as often as one every 2 minutes. These interruptions often occur while staff are performing complex tasks such as medication order review, verification, preparation, and dispensing, and may involve multiple layers of task switching that make it difficult to return accurately to the original task. Evidence links I&Ds to higher medication error rates, with increased errors observed when prescriptions were processed amid interruptions or distractions. Common errors include dispensing mistakes, omissions, and delays. Major sources of disruption include phone calls, inquiries from nurses or other healthcare professionals, interpersonal conversations, and internal workflow inefficiencies. Phone calls are consistently identified as the dominant source of interruption, with many related to missing medications. Staff frequently attempt to multitask during interruptions, such as verifying orders or preparing medications while on calls, but these workarounds may further increase risk. [3]
Calls to action emphasize a comprehensive, systems-based strategy to reduce pharmacy I&Ds by addressing root causes, redesigning workflows, and protecting staff focus during critical tasks. A primary priority is reducing missing medications, a major driver of phone calls and workflow disruption, through improved dispensing reliability, inventory management, standardized medication delivery processes, and real-time tracking technology that allows nursing staff to locate doses without contacting the pharmacy. Pharmacies should redesign communication processes so medication inquiries are handled efficiently through dedicated staff, rotating triage roles, centralized call management, or designated resources separated from personnel processing new medication orders. Cycle time for resolving inquiries should be minimized to reduce prolonged task disruption. Workflow should be structured to insulate pharmacists and technicians performing order entry, verification, compounding, and dispensing from unnecessary interruptions, similar to protections often afforded prescribing and medication administration tasks. Multidisciplinary collaboration among pharmacy, nursing, medicine, and administration is essential to address recurring sources of interruptions and align expectations around communication. Hospitals should also leverage pharmacy information systems, automation, barcode technology, and clinical decision support to streamline operations while recognizing that technology alone does not resolve human-factor risks. By systematically reducing interruptions and distractions, organizations can decrease medication errors, improve operational efficiency, free pharmacist time for higher-value clinical services, and enhance staff job satisfaction and patient safety. [3]
A 2013 analysis meticulously examined the prevalence and impact of distractions and interruptions in a pharmacy setting, specifically focusing on their correlation with dispensing errors. Observations were conducted in the main dispensing zone of a pharmacy department in a 500-bed mother–child teaching institution. The environment was studied to identify and categorize various stimuli that could disrupt workflow. During a two-hour pilot phase, researchers identified 25 types of stimuli, distinguishing them based on whether they systematically caused task interruptions. Notably, face-to-face conversations, fire alarms, and pneumatic tube system noise were among the common stimuli identified. The study achieved a comprehensive evaluation by observing 62 periods of 30 minutes each, resulting in 2,663 stimulus events recorded, with interruptions more frequently affecting pharmacists than technicians. Results from this 2013 study highlighted a significant association between the frequency of interruptions and the occurrence of dispensing errors, primarily labeling errors. The analysis conveyed that distractions increased task completion time by 27% when compared to uninterrupted tasks. Moreover, implemented corrective actions post-observation included reorganizing the physical layout, limiting non-essential staff movement, discouraging non-professional conversations, and introducing technological enhancements such as digital fax systems to reduce environmental noise. The study underscores the importance of mitigating interruptions to enhance medication safety and efficiency in pharmacy operations, driving home the need for ongoing efforts to address these operational challenges. [4]
A 2017 quasi-experimental study evaluated the impact of telephone-call interruptions on pharmacy workflow and communication within the inpatient pharmacy at Prince Sultan Military Medical City. Recognizing that frequent calls from nursing units contributed to pharmacist workload, task interruptions, delayed turnaround times, and potential medication errors, investigators sought to develop a system-based solution to reduce unnecessary telephone communication between pharmacy and nursing staff. Baseline data collected over a two-week period showed that the inpatient pharmacy received 3,328 incoming calls and made 1,138 outgoing calls, totaling 4,466 calls, with follow-up inquiries regarding prescription status representing the most common category of incoming calls. To address this, a multidisciplinary team implemented a phased intervention that included paper-based communication tools followed by development of integrated web-based pharmacy and nursing portals that enabled electronic prescription tracking, bidirectional messaging, prioritization of urgent medication requests, and real-time status updates. Following implementation, incoming calls significantly decreased from 3,328 to 1,796 and outgoing calls declined from 1,138 to 834, reducing total call volume to 2,630. Calls related to prescription confirmation, follow-up, IV discontinuations, and routine status requests were significantly reduced, while remaining calls shifted toward more clinically relevant professional inquiries. The study concluded that technology-enabled communication and tracking systems can substantially reduce avoidable interruptions, improve interdepartmental workflow, and allow pharmacists to focus more effectively on medication safety and patient care activities. [5]
A 2023 single-center, cross-sectional study utilized a synthetic approach integrating resilience engineering and systems thinking to address workflow interruptions within a Japanese hospital pharmacy. The research was conducted at Osaka University Hospital's inpatient medication dispensing unit for oral and topical medications (IMDU-OT). Data collection involved interviews with pharmacists, workload metrics, and a detailed audit of telephone inquiries and counter service interactions over five business days. The study aimed to identify how adaptive behaviors employed by pharmacists and nurses to manage workload constraints—such as short staffing and limited medication delivery schedules—contributed to frequent workplace interruptions, primarily through phone requests and counter services. The implemented interventions included the introduction of a medication tracking system, request-based extra medication deliveries, and pass boxes for earlier medication pickup. Four months post-intervention, the daily median number of interruptions was reduced by 60%, from 43 to 18 telephone inquiries and from 55 to 15 counter service requests. These results underscore the effectiveness of mitigating cross-system performance adjustments, thereby significantly decreasing interruptions to the pharmacists' workflow. [6]