Key to medication safety is the careful review of orders by a pharmacist before a medication is dispensed. This concept is clearly reinforced by The Joint Commission’s Medication Management Standard (see SIDEBAR). Conversely, consideration must be given to situations wherein a delay resulting from pharmacist review could potentially harm a patient. Fortunately, today’s automated dispensing cabinets (ADCs) include a provision to release medications via an override, should a nurse urgently require a medication.
For the vast majority of medication removals, there is adequate time for the important safety step of pharmacist review of the medication order. Considering this, and the fact that many regulatory agencies are clear in stating their expectations that not just any medication be assigned override status, careful consideration must be given to deciding which medications should be added to the override list in the ADC. In order to ensure the override list is safe and effective, a comprehensive override policy first must be created. The policy will then guide the list creation and maintenance processes and ensure that ongoing monitoring of overrides supports facility-wide medication safety efforts.
At the Palomar Health facilities located in San Diego County, California, the ADC override policy and the override list are managed by the pharmacy department. The list of override medications is programmed into the ADC system and includes only those drugs indicated for severe pain relief, emergent bedside procedures, patient rescue, and cardiopulmonary arrest. Oral medications usually are not permitted on our override list; they are not considered urgent medications as oral absorption typically takes a few minutes. The override list is reviewed in its entirety by the Pharmacy and Therapeutics (P&T) committee at least annually.
Employing the Override Function
Nurses removing medications from the ADC on an emergent basis must first determine if either of the following scenarios exist:
Only when one of these two conditions exists should the nurse remove the medication from the ADC using the override function. At our institution, we require the nurse to indicate the reason (ie, specific indication) for each overridden medication in a free text message field on the ADC. Examples of acceptable indications include:
For those scenarios when the physician will be at the patient’s bedside, we require the nurse include this fact in the documentation by indicating both the reason for the override and the physician’s name in the ADC’s message field (eg, Procedure, Dr. Smith present). Once this documentation is provided in the ADC, the nurse can remove the medication for administration.
Establishing the Override Policy
The ADC override policy should be carefully crafted and should include an explanation of the reasons that an override list is needed, in addition to stating why the list must be carefully developed and maintained. The policy should clearly delineate the responsibilities and expectations for pharmacists, nurses removing medications, and even nurse managers, who are responsible for reviewing anomalies. At our hospital, we found it advantageous to create three separate override lists. The first applies to the general staff nurses; the second list includes additional medications specific to the labor and delivery unit; the third list is designed to meet the needs of the critical care unit, and as such, includes more emergency medications than are available to the general staff nurses. Access to these different override lists is controlled through user templates in our ADC system. It is important to include a requirement that all medications administered by hospital staff members have a corresponding provider order in the medical record.
Managing the Override List
On occasion, clinicians may request that additional medications be added to the override list to allow for easier access. The P&T Committee should carefully assess the validity of every request. Likewise, any requests to remove medications from the list also require thoughtful consideration. Criteria to consider when a medication is proposed for addition might include the potential for harm if pharmacist review is bypassed during the override, whether it is a rapid-acting medication, and if the medication is used for truly emergent situations. Medication deletions often are proposed in response to patient harm resulting from an override, or a medication error related to the override. For example, heparin drips recently were removed from the Palomar Health override list following an incident in the emergency room in which the drip was mistaken for heparinized saline. Until this event, overrides had been permitted for heparin drips. Similarly, a medication error occurred on the labor and delivery unit when a nurse overrode vitamin K for injection and then inadvertently switched it with a look-alike drug. After careful review of the incident, the multidisciplinary team determined that vitamin K administration was not sufficiently urgent and removed the medication from the override list. Review of the override process must be an ongoing responsibility for the pharmacy department, not only to identify potential medication errors, but also to ensure that nurses are confident in using the override feature when it benefits their patients’ care.
To ensure the ongoing effectiveness of the override policy, the practice should be assessed on a regular basis. Monitoring how the override function is used is a regulatory agency expectation; as such, the pharmacy department must regularly review reports created from the ADC system that detail override use, and these actions must be documented. Daily reviews of medication overrides should be conducted by a pharmacist, with the goal of identifying any potentially inappropriate usage. Issues to look for during the review process include:
Any identified issues should then be transcribed to an override variance report and communicated via email to the appropriate nurse manager. At Palomar Health, the pharmacist conducts the initial review to identify any issues on the report, and then the compliance specialist technician completes the communication part of the process by sending an email to the respective nurse manager. It is important to set the expectation that the nursing manager will carefully review the potentially inappropriate override and discuss the incident with the staff nurse. Prompt communication back to the pharmacy detailing how the incident was resolved allows pharmacy to close the incident; the nurse manager is expected to respond within 5 business days. Finally, the pharmacy documents any subsequent changes to the nursing unit’s override compliance rate.
A safe override process is built on a carefully crafted policy. The same thoughtful foresight is required to create an effective list of override medications. Investing the time up front to create a thorough policy will result in fewer adjustments thereafter and will deliver the safety our patients deserve. Ultimately, a well-written policy also can serve as a teaching tool for new staff so they can better understand the need for careful pharmacist review of most medication orders, while at the same time learning when it is appropriate for the medication override function to be used.
Bill Turner, RPh, is the pharmacy manager at Pomerado Hospital. Bill has served as a pharmacist for 34 years, 20 of which have been spent in both clinical and operational management. He obtained a BS in pharmacy from the University of Wisconsin-Madison. Bill finds true professional satisfaction in managing his great team of people and precepting pharmacy students.
The Joint Commission states in its Medication Management Standards for hospitals the following: “Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation.”1