PROBLEM: Distracted practice is the result of individuals interacting with the environment and technology in the performance of their jobs. The resultant behaviors can lead to error and affect patient safety.

METHODS: A qualitative descriptive approach was used that integrated observations with semistructured interviews. The conceptual framework was based on the distracted driving model.

FINDINGS: There were 22 observation sessions and 32 interviews (12 RNs, 11 MDs, and 9 pharmacists) completed. Results suggested that distracted practice is based on the main theme of cognitive resources, which varies by the subthemes of individual differences, environmental disruptions, team awareness, and "rush mode"/time pressure.

CONCLUSIONS: Distracted practice is an individual human experience that occurs when there are not enough cognitive resources available to effectively complete the task at hand. In that moment an individual shifts from thinking critically, being able to complete their current task without error, to not thinking critically and working in an automatic mode. This is when errors occur. Understanding the role of distracted practice is essential for reducing errors and improving the quality of care. Additional research is needed to evaluate intervention strategies to reduce distracted practice.