Medication Pass Total Recall

Recovering from interruptions for enhanced patient safety

For the majority of unit nurses, a typical day has two certainties: interruptions and distractions. As the go-to staff for a multitude of needs, nurses are often responsible for balancing many tasks at once and must seamlessly navigate any disruptions along the way while also successfully completing their critical tasks.

Recent findings1 reveal that nurses experience an average of 6.7 interruptions per hour during their shifts. Another report2 found that nurses are distracted during the medication process, in particular, every two minutes. Such disturbances can lead to anything from a minor transcription error to a life-threatening sentinel event for patients.

In fact, some researchers found a direct relationship between the frequency of interruptions and the likelihood of medication error. One study3 observing nurses during medication administration found that each interruption had a 12.1% increase in procedural failures and a 12.7% increase in clinical errors.

While the five rights of medication administration-the right patient, the right drug, the right time, the right dose and the right route-are a high priority in nursing workflows, interruptions can introduce a significant window for error for nursing professionals, who can lose focus and make mistakes. Ideally, the medication pass process should remain unadulterated to ensure the highest level of patient safety.

Nurse distractions: A deeper look

Consider this typical dispensing scenario: A nurse is pulling medications at an automated dispensing cabinet (ADC) when another clinician interrupts to ask a question about a patient. After addressing the question, the nurse continues the dispensing process, but is interrupted again when another colleague needs an emergency medication and requests immediate access to the cabinet, requiring that the original medication pass process be put on hold again.

Once the nurse returns to the cabinet and medications are finally dispensed, he or she must still contend with what is commonly referred to as the “last 50 feet” of the medication administration process-or the last few steps to the patient’s room. The likelihood of further disruption escalates as the nurse walks to the patient’s room, encounters any of the patient’s visitors or additional staff and attempts to complete the medication pass.

Nurses carry heftier patient care responsibilities today than ever before, which makes it challenging to address and mitigate all of these types of workflow disruptions. While the scenario just described points to typical day-to-day distractions, a number of other possibilities such as shift changes and stockouts can also contribute to the potential for error.

Yet there are ways to effectively circumnavigate the issue if nurses can recall and retrace steps when the medication pass process is compromised. Moreover, they need straightforward solutions to remember exactly where they were in the medication process before a disruption in order to avoid any potential oversights.

A better medication pass workflow

Industry evidence consistently points to the positive impact of medication distribution solutions on patient safety and workflows. Among them are advanced ADCs that can better equip nurses to respond to interruptions by reminding them specifically about which tasks were completed-and which ones were not-when the distraction occurred. As healthcare organizations continue to embrace many technology-enabled workflows as best practices, clinical leaders can leverage enhancements to ADCs to help improve the medication pass process.

Features such as “save and quit” and “bag and label,” for example, help nurses know exactly where they left off following an interruption. With the push of a button, they can sign off from the ADC and receive a printed patient label that describes all completed activity, which can then be affixed to the bag of medications already removed. (instead of:  as well as a bag of labeled medications by patient).  When the nurse signs back in to the ADC, it will allow work to be picked up exactly where he or she left off-rather than trying to manually recall the completed steps.

Advanced functionality also can improve the outlook on medication wasting. Since these processes often require the presence of a witness, nurses typically complete them after they leave a patient’s room. Any distractions experienced during the walk back to the nursing station can inadvertently cause these procedures to be neglected. As a result, some ADCs now remind nurses of the need to waste a medication when they return to retrieve another round of medications.

An optimistic look into the future

Workflow interruptions are a well-documented hindrance within many medication administration processes in today’s hospitals and health systems. Fortunately though, with the right technological framework, they can be addressed with a simple solution that allows the nurse the ability to respond to disruptions and/or interruptions as they arise, without sacrificing patient safety or care delivery. By equipping nurses with efficient and accurate recall of the medication pass steps completed, as well as dispensing medications in a sealed and labeled container, hospitals can further prioritize patient safety and better ensure that the five rights are validated.


  1. Biron, AD, Loiselle, CG, Lavoie-Tremblay, M. ‘Work interruptions and their contribution to medication administration errors: an evidence review.’ Available at:
  2. Relihan, E, O’Brien, V, O’Hara, S, Silke, B. ‘The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration.’ Available at:

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