Mitigating interruptions during medication ordering and transcription

May 2011 to December 2011


Previous research by HumanEra found a link between interruptions and medication administration errors in an oncology nursing environment. The study also demonstrated a measurable improvement in medication errors after the implementation of a variety of strategies for mitigating interruptions. Unfortunately, interruptions are not limited to the medication administration phase; they also occur during medication ordering and transcription, despite Accreditation Canada standards requiring hospitals to provide designated “quiet work areas where medication orders are written or transcribed.” As in many hospitals, ordering physicians and triage pharmacists at CancerCare Manitoba are currently working in relatively busy and noisy team environments. As such, HumanEra worked with CancerCare Manitoba to further investigate the effects of interruptions during medication ordering and transcription.

Objectives for this project were to:

  • Quantify and classify interruptions experienced by ordering physicians and triaging pharmacists
  • Establish a baseline rate of medication ordering and checking errors
  • Measure the impact of the presence of a clinic pharmacist on the types and frequency of interruptions and on error rates.

Results showed the main reasons for interruptions in oncology clinics were communication events (e.g., asking questions related to patient assessments, patient history, and medication orders). HumaEra therefore recommended that completely eliminating sources of interruptions is therefore neither feasible nor suggested. Instead, efforts should be made to minimize the impact of interruptions occurring during safety-critical tasks and/or increase oncologists’ resiliency to interruptions.

Another result was that pharmacists in clinic were found to play an important role in communication and medication order quality, and triage pharmacists were found to have resolved many potentially serious medication order quality issues. Thus, HumanEra recommend that pharmacy programming should continue to be supported, and interdisciplinary communication between oncologists and pharmacists should be further encouraged.

Funding Agency

CancerCare Manitoba

Project Sponsor

Patricia Trbovich



Trbovich, P. ( 2012, Oct). Effect of Interruptions on Chemotherapy Ordering and the Impact of Clinical Pharmacists on Medication Order Quality. Presented at the National Oncology Pharmacy Symposium 2012, Saskatoon, Saskatchewan.

Project Team

Melissa Griffin
Rachel White
Stacey Howchin (student)
Nancy Ho (student)

For more information on this project, contact:

Patricia Trbovich