High interruption rates threaten patient safety

New research has found that pharmacists are interrupted at alarming rates when dispensing medicines.

Led by Monash University’s Faculty of Pharmacy and Pharmaceutical Sciences, the study aimed to review existing evidence on how interruptions and distractions in pharmacy practice influence the occurrence of dispensing errors.

The review, which analysed 51 Australian and international studies, found that pharmacists can experience interruptions and distractions more than 20 times per hour.

Phone calls were the biggest disruptor, said co-author Associate/Professor Dan Malone MPS, Course Director of the Undergraduate Pharmacy Degree.

‘For example, where a pharmacist would be dispensing or talking to someone, and either the phone was ringing or they would be interrupted by a colleague who said there was a phone call for the pharmacist,’ he said.

Other key disruptors during dispensing included:

• consumers interrupting pharmacists to ask a question
• interruptions and distractions from pharmacy staff who needed to manage customer queries that were out of their scope.

What are the impacts of interruptions?

While most studies included in the review identified what the interruptions were and how frequently they occurred, few looked at the impact of interruptions and strategies to mitigate them.

But of those that did, medication errors were the most serious issue identified.

‘While no medication error should occur, some are relatively minor whereas others are potentially fatal,’ A/Prof Malone said.

Other identified impacts included: 

• taking longer to dispense a script
• poorer performance 
• mental fatigue.

What about self-interruptions?

It’s not always external interruptions that are the culprits. Sometimes, it’s the pharmacists themselves who self-interrupt, the review team found.

‘They might be working on a particular task, then start searching the internet on an unrelated topic,’ A/Prof Malone said. ‘Or talk to their colleague while dispensing – initiating an interruption themselves.’ 

The term that’s often used for this phenomenon is ‘multi-tasking’. But A/Prof Malone said it’s more akin to task-switching.

‘There’s a lot of evidence that suggests jumping from one task to another is not an efficient way to work, and it’s also more likely to introduce errors into the process,’ he said.

What are the key intervention strategies?

Should pharmacists be better trained to deal with inevitable interruptions, or should pharmacy teams try to reduce those interruptions in practice? 

A bit of both, A/Prof Malone thinks.

‘Our pharmacy students do a lot of practice in terms of role playing the pharmacist in a workshop, for example,’ he said. ‘But when they go out on placement, they often complain that “it’s really noisy, there’s all these distractions and it’s hard to concentrate”,’ he said. 

‘There’s a lot of evidence that suggests jumping from one task to another is not an efficient way to work, and it’s also more likely to introduce errors into the process,.’

DAN MALONE MPS 

Better preparing students for that environment by stimulating situations where interruptions occur should help them to cope with future interruptions, A/Prof Mr Malone said.

And while interruptions can’t be eliminated completely, systems can be put in place to reduce them, including:

• having a set time where the pharmacist can’t be interrupted
• making sure there’s workflow processes to ensure the pharmacist is less likely to be interrupted.

‘For example, when a prescription is dispensed, having a process whereby communication is such that the pharmacist is able to focus on the dispensing process,’ A/Prof Malone said. ‘When another prescription comes in, unless it’s urgent, the pharmacist isn’t interrupted – so they can go through the dispensing process with one prescription before they start the next.’

Or it might just be a matter of staffing.

‘Where possible, having two pharmacists on, with one focusing on tasks such as patient queries – limiting direct access to the other pharmacist during dispensing time,’ he said.

However, in practice this isn’t always possible. When more urgent matters arise – as they inevitably do – pharmacists often have to park what they’re doing and switch tasks. 

‘That’s understandable, but it’s preferable to minimise these occurrences, if possible,’ A/Prof Malone said.

What about training other staff?

There’s a ‘huge benefit’ in having well-trained pharmacy assistants on staff to reduce interruptions, and therefore errors, A/Prof Malone said.

‘I’ve worked with a lot of really experienced pharmacy assistants who know a lot about disease states, and are able to handle queries that come in and field questions over the phone without necessarily having to speak with the pharmacist,’ he said.

But there are limitations to this approach, including making recommendations about Schedule 3 medicines.

‘This requires the pharmacist to be interrupted,’ A/Prof Malone added.

PSA’s Pharmacists in 2030 recommends recognising and formalising the role of pharmacy assistants as well as technicians by establishing clear development pathways, such as:

• registering support technicians to perform final-checking duties
• embedding Certificate II, III and IV dispensary technician qualifications into practice to free pharmacists for direct patient care.

To safeguard pharmacist wellbeing and minimise medicine errors, Pharmacists in 2030  advocates for:

• enforcing safe-dispensing limits through patient-to-pharmacist ratios
• building mandatory rest breaks into rosters
• providing Employee Assistance Programs 
• redesigning workspaces to enhance comfort and support mental health.

What’s next on the horizon?

The paper, led by pharmacist and PhD student Meaza Ayanaw, is a scoping review that’s paving the way for further research into how interruptions and distractions affect pharmacists’ decision-making ability, and how pharmacists prioritise different tasks. 

‘For example, should pharmacists switch tasks when they’re in a pharmacy environment? If so, when should they switch? And what are the high- and low-priority tasks that require pharmacists to switch?’ A/Prof Malone said.

From the results of the findings, more assessments and training will be developed using simulations such as Monash’s MyDispense.

‘This will help students to prepare for [pharmacy practice] by reflecting on real-world interruptions and distractions in a simulated environment. So that when they make mistakes, there’s no consequence associated,’ A/Prof Malone said.

For more information on streaming workflows and operations, don’t miss the poster presentation ‘Optimising pharmacy operations’ at PSA25, from 1–3 August 2025. Register here to attend.