CHPPC Module 26, Section 3: Interruption Management
MODULE 26: QUEUE COMMAND: TIME-TRIAGE FOR VERIFICATION UNDER FIRE

Section 26.3: Interruption Management: Pausing Safely, Resuming Cleanly

The Cockpit Discipline: A Sterile Process for Handling Distractions and Preserving Safety Under Pressure.

SECTION 26.3

Interruption Management

Developing the discipline to manage the single greatest threat to medication safety during verification.

26.3.1 The “Why”: The Unseen Danger of a Divided Mind

In the complex and chaotic environment of a hospital pharmacy, interruptions are not a possibility; they are a mathematical certainty. The phone will ring, a technician will have a question, a nurse will appear with an urgent problem, a STAT order will drop into your queue. While you may have learned to handle these distractions in your retail practice, the hospital environment amplifies the risk exponentially. The complexity of the orders is higher, the acuity of the patients is greater, and the sheer volume of data you are processing for each decision is immense. Studies from the Institute for Safe Medication Practices (ISMP) and others have repeatedly identified interruptions as one of the leading root causes of catastrophic medication errors.

The danger is not the interruption itself, but the way it fractures your cognitive focus. When you are deep in the process of verifying a complex order—checking labs, calculating a dose, reviewing allergies—your brain is holding a dozen different data points in its working memory. An interruption shatters that delicate mental construct. When you return to the task, your brain doesn’t just pick up where it left off. It’s like trying to reassemble a broken vase; pieces are often missing or put back in the wrong order. You might forget the lab value you just saw, skip a crucial step in your mental checklist, or misremember a key detail.

Therefore, managing interruptions is not a “soft skill”; it is a hard, evidence-based patient safety discipline. It requires a systematic, ritualized process for pausing a task safely, handling the interruption, and, most importantly, resuming the task cleanly. This section will provide you with that system, a framework modeled on the high-stakes world of aviation, designed to protect your focus and safeguard your patients from the unseen danger of a divided mind.

26.3.2 The Analogy: The “Sterile Cockpit” Rule

A Deep Dive into the Analogy

In commercial aviation, it was discovered that a significant number of accidents were caused by pilot error during the most critical phases of flight. Investigations revealed that these errors were often linked to distractions and non-essential conversations in the cockpit. In response, the Federal Aviation Administration (FAA) created one of the most powerful safety rules in any industry: the Sterile Cockpit Rule.

The rule is simple but absolute. During all “critical phases of flight”—defined as all ground operations, takeoff, landing, and all flight operations below 10,000 feet—all non-essential activities and conversations are strictly forbidden. The pilots must focus exclusively on the safe operation of the aircraft. No chatting about the weather, no discussing the previous night’s game, no food service coordination. The cockpit must be “sterile.”

For a hospital pharmacist, the act of verifying a medication order is a critical phase of flight. From the moment you open a patient’s chart to the moment you click “Verify,” you are flying below 10,000 feet. The potential for a catastrophic error is at its highest. This section will teach you how to implement your own personal Sterile Cockpit Rule. It’s not about being rude or antisocial; it’s about recognizing that for those 60-90 seconds of intense focus, your absolute, undivided attention is required to ensure your patient lands safely.

Masterclass Part 1: The P-R-R Framework — Pause, Resolve, Resume

This is your systematic, three-step process for handling any interruption. The goal is to turn an unconscious, risky reaction into a conscious, safe, and repeatable procedure. This framework must become a deeply ingrained habit.

(P) Step 1: PAUSE — The “Sterile” Stop

When an interruption occurs, your first instinct might be to multitask—to try and listen to the question while simultaneously finishing your verification. This is the single most dangerous action you can take. You must learn to execute a “sterile stop” before you ever engage with the interruption.

The Mechanics of a Safe Pause:
  1. The Physical Signal: Develop a physical habit that signals to your brain that you are pausing. A simple, effective technique is to take your hand completely off the mouse and place it palm-up on your desk. This physical act breaks your momentum and creates a clear “before” and “after” state. It’s a physical bookmark.
  2. The Digital Bookmark: If your EHR allows it, use a “parking” function or leave a comment on the order you are pausing. A simple note like “-PAUSED TO TAKE CALL-” creates a digital breadcrumb that tells you (or another pharmacist) the status of this order.
  3. The Verbal Shield: For non-urgent interruptions (e.g., a colleague asking a casual question), you must deploy a “verbal shield” to protect your sterile cockpit. This is a polite but firm way of deferring the interruption for a few critical seconds. Mastering this script is essential.
The Verbal Shield Script

When someone approaches you while you are verifying, make eye contact, put up one hand in a gentle “stop” gesture, and say one of the following with a calm, professional tone:

Script A (For a 30-second task): “I’m right in the middle of a critical order. Give me just 30 seconds to finish this safely, and then you will have my full attention.”

Script B (For a longer task): “I need to finish this chemotherapy verification without distraction. Can I please find you in about five minutes as soon as I am done?”

Why this works: You are not being rude. You are communicating that you are engaged in a safety-critical task, providing a specific timeline, and promising your full attention. This shows respect for both the person asking and the patient you are protecting.

(R) Step 2: RESOLVE — Triaging the Interruption

Once you have safely paused, you can now turn your full attention to the interruption itself. Your goal is to resolve it as efficiently as possible. This involves its own rapid triage process.

  • Is it a true emergency? (e.g., a STAT page, a Code Blue call) -> Handle it immediately with your full focus.
  • Is it an urgent operational question? (e.g., a tech needs a check, a nurse is waiting for a med) -> Handle it now, but be concise.
  • Is it a non-urgent question? -> Answer it quickly or, if it requires a longer explanation, schedule a time to follow up. (“That’s a great question. I need to look up a few things. Let me finish what I’m doing and I’ll come find you in 15 minutes with the answer.”)

(R) Step 3: RESUME — The “Clean” Restart Checklist

This is the most important, and most frequently skipped, step in the entire process. Returning to an interrupted task is where the majority of errors occur. You cannot simply trust your memory. You must assume your working memory has been wiped clean and perform a systematic, ritualized restart.

The Catastrophic Error of the “Quick Resume”

A classic error involves a pharmacist who is verifying a pediatric antibiotic dose. They correctly calculate the dose based on weight (e.g., 250 mg). They are then interrupted by a phone call. After the call, they return to the screen, but their eyes fall on the patient’s age (e.g., “10 years old”). Their brain misfires, and they quickly type in a standard adult dose (e.g., 1000 mg), forgetting the crucial weight-based calculation they did just moments before. This is called a “slip” or “lapse,” and it is a direct result of not performing a clean restart. The following checklist is your defense against this.

Your Mandatory “Clean Restart” Checklist

You must perform this 6-step check every single time you return to an interrupted verification. No exceptions.

Step Action Rationale
1. Re-Identify the Patient Look at the patient banner. Verbally or sub-vocally say the patient’s name and check their two identifiers (e.g., MRN, DOB). Prevents you from accidentally continuing your work on the wrong patient’s chart if the interruption caused you to click elsewhere.
2. Re-Identify the Medication Look at the order. Verbally or sub-vocally state the full drug name, dose, route, and frequency. Refreshes your working memory with the core details of the specific task you were performing.
3. Re-Read the Original Order Force yourself to read the provider’s original order text from the beginning to the end. This is the most critical step. It prevents errors of omission where you might have stopped halfway through reading a complex sig before the interruption.
4. Review Your Last Action Identify the last physical or mental step you completed. “Okay, I had just finished calculating the creatinine clearance, which was 25.” or “I had just opened the interaction checker.” This re-establishes your exact place in the workflow and prevents you from either skipping a step or re-doing work unnecessarily.
5. Scan for Changes Perform a quick scan of the chart for any new, critical information that may have appeared while you were distracted. The most important place to look is at new lab results. A new critical lab value (e.g., a high potassium, a low platelet count) could completely change the safety or appropriateness of the order you were about to verify.
6. Proceed with Verification Only after completing the first five steps should you resume the verification process from the point you identified in Step 4. You have now successfully rebooted your “mental software” and can proceed with a high degree of safety.

Masterclass Part 2: Creating a “Zone of Focus”

While the P-R-R framework helps you manage interruptions when they occur, an equally important strategy is to proactively minimize the number of interruptions you face in the first place. This involves a combination of environmental controls and team-based agreements.

Strategies for Building Your “Sterile Cockpit”
  • Control Your Environment: If possible, position your workstation so you are facing away from high-traffic areas. This reduces visual distractions. If your department policy allows, using one earbud with ambient noise or classical music can help drown out distracting background conversations.
  • Use Visual “Do Not Disturb” Signals: Some pharmacies have implemented simple but effective visual cues. This could be a small, laminated sign that says “Chemotherapy Verification in Progress – Please Do Not Disturb” that a pharmacist can place on their monitor. This signals to colleagues that you are in a high-stakes task.
  • Advocate for a “No Interruption Zone”: Many hospitals have created a designated “quiet zone” or a specific workstation for the verification of high-risk medications like chemotherapy or parenteral nutrition. In this zone, interruptions are culturally forbidden.
  • Implement a “Buddy System”: During the busiest parts of the day, work with a pharmacist colleague to divide and conquer. One pharmacist can be the designated “interruption handler,” taking all the phone calls and answering operational questions for a set period (e.g., one hour), allowing the other pharmacist to verify orders with minimal distraction. Then, you switch roles.
  • Educate Your Colleagues: Have a professional, team-based conversation about the dangers of interruptions. Share an article from ISMP. By framing it as a shared patient safety goal, you can get buy-in from your entire team to respect each other’s “sterile cockpit.”