1. Module 12
Medication Pass
No Interruptions

2. Medication Errors
The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as follows: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer

3. Causes of Medication Error
Multiple factors can contribute to medication errors
including nurse’s workload
experience level
transcription errors, and system deficiencies
Distractions and interruptions

4. Interrupted Workflow
In a French study, Tissot and colleagues reported that interrupted workflow during medication administration was a contributing factor to the 6.6% error rate in medication administration.

5. Interruptions
a break in continuity of complete focus on the task of preparing medication
verbal or nonverbal cue from another individual prompting the nurse to give a verbal or nonverbal response
losing focus on medication preparation and initiating conversation with another person

6. Strategies to Reduce Errors
Computer-based order entry
Patient and medication barcode scanning
The “Sterile Cockpit Rule”
No Interruption Zone (NIZ)

7. Sterile Cockpit Rule
The Federal Aviation Administration in 1981 enacted policies that prohibit nonessential tasks and communications by aircraft personnel during flight operations
Distractions and interruptions resulting in omissions or inappropriate actions during flight operations
This adherence to the sterile cockpit rule minimizes distractions during critical periods of flight operations and improves airline safety.

8. No Interruption Zone
The NIZ is fashioned after the aviation industry’s “sterile cockpit rule.”
Change in nurses’ ability to pass medications more efficiently and think more clearly.
No interruptions during med pass
Do not allow distractions
Avoid personal conversations
Avoid phone calls
No multitasking

9. Prevent Phone Distractions
Communicate prior to passing medications that you will unable to answer the phone and to take a message
Place your phone on vibrate
Leave your phone with another nurse
Do not multi-task
Do not answer the phone while preparing or administering medications

10. Patient Safety Nurses are primarily responsible for medication safety
National initiatives are calling for an increase in medication safety
During medication preparation, a No Interruption Zone could decrease interruptions and enhance safety
Reference Anthony, K., Wiencek, C., Bauer, C., Daly, B. and Anthony, M. K. (2010). No interruptions please: Impact on a no interruption zone on medication safety. Critical Care Nurse 2010, 30: doi: /ccn © 2010 American Association of Critical-Care Nurses. Retrieved from: