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Improvement Studies-Medication Errors

The Impact of Cognitive Load, Interruptions, and Distractions on Procedural Failures and Medication Administration Errors

Principal Investigator: Lily Thomas, PhD, RN
Co-Principal Investigator: Patricia Donohue-Porter, PhD, RN


Specific Aims:

  • To identify the impact of interruptions and distractions on medication administration errors
  • To design interventions that will assist in diminishing the impact of interruptions and distractions while administering medications

Background and Significance:

Patient safety and quality improvement are clearly-stated national priorities (IOM, 1999, 2001, 2003, 2004).  Medication administration errors remain a central area of concern in the landscape of patient safety and quality. These errors remain a significant cause of mortality and morbidity and have been estimated to result in more than 7000 deaths nationally (IOM, 2006) and 96% of the errors were preventable (Picone 2008). One third of errors harming patients occur at the medication administration stage; nurses safeguard up to 86% of all errors made by others in providing medications (Leape, 1995). However, medication administration has few safeguards because it is at end of process.

Research Design and Methods:

This multisite, two phase study will begin with a descriptive-correlational phase identifying and describing the relationship of various types of interruptions and distractions with the medication administration process. The second phase of the study will test interventions to reduce the impact of interruptions and distractions, thus preventing medication errors.

To download the study prospectus, click here.

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