The safety benefits that can be reaped as a result of employing profiled automated dispensing cabinets (ADCs) for increased medication safety are clear. Creating and using profiles is one of the most important ADC safety improvements in recent years, since it ensures that only intended drugs are made available at the ADC, the drugs are validated, and the profile is updated before the drugs reach the patient. However, in a recent ISMP survey, just 59% of respondents reported that all ADCs in their facilities are capable of profiling.1 Lack of pharmacist profiling allows for the possibility of errors and potentially dangerous adverse drug events during that sensitive transition period between removing the drug from the ADC and administering it at the bedside.
Profiling does create a point of contention for some, as an argument can be made that profiling limits access to emergent drugs. As such, facilities that use ADCs need to create contingency plans in case of emergency. Most commonly this need is met by the development of a drug override list, which allows unrestricted access to a limited group of medications during an emergency. While override lists are necessary, well-thought-out policies and procedures and a hospital culture of safety are necessary as well, so that the override list does not become a workaround for nursing when faced with frustrating technology issues. Preventing unnecessary overrides—and managing legitimate ones—can be the difference between a facility that simply maintains the status quo and one that continually strives for consistent and safe medication practices.
Regulating Use of Overrides
While overrides are a means to meet a specific need, it is exceedingly common for staff to use them improperly. The Joint Commission requires a pharmacist to review all orders prior to administration, with only two exceptions—⎯they allow for immediate administration when the delay in order review would lead to patient harm, or when a licensed independent practitioner controls the prescribing, dispensing, and administering of the drug. Thus, the most important test of the override list is ensuring drugs and their approved uses are consistent with this regulation.
Creating an Override List
Each facility needs to consider its unique needs to determine the medications that belong on the override list. Remember that override lists should not be a substitute for pharmacy order review and dispensing of medications. Also, all of the medications on the list should be included for only one approved indication. For example, our facility, Lehigh Valley Hospital in Allentown, Pennsylvania, placed morphine on our override list for chest pain. It should not be removed using the override function for every morphine order, just the emergent ones. Standard pain medication orders should be run through the profile and removed only after the order has been verified by pharmacy. At Lehigh, morphine is not approved for override for other pain indications, only chest pain.
The Role of the Medication Safety Team
The content of our override list is managed by the hospital’s medication safety team, a multidisciplinary team that is lead by the medication safety officer and includes members of pharmacy leadership, staff nurses, nursing administration, nursing education, and risk management. When a staff member requests that a medication be added to the override list, the team carefully weighs the pros and cons of adding that drug, taking into account how much time it takes for orders to be verified, as well as how likely risk for harm is as a result of bypassing the pharmacy verification step. After fully evaluating the implications of adding the requested medication, the team’s decision is communicated back to the requestor. This information also helps to educate the requestor and emphasizes the importance of following standard processes.
Depending on the facility, it might be necessary to create more than one override list. After evaluating our needs, the medication safety team decided that Lehigh Valley would benefit from five lists, as the ED, OB, ICUs, medical-surgical units, and pediatric units all have different needs and treat different types of patients. Developing specific lists for the various hospital areas has allowed us to consider each area’s needs more carefully and provide an override list appropriate to that treatment area.
Maintaining Complete Orders
There is little doubt that even when used appropriately, overrides raise the risk of error. To minimize this risk, the most important step in the process of removing drugs from ADCs is to have a complete order. Aside from cardiac and respiratory arrests that are usually handled by an emergency code cart, there are few circumstances in which verbal orders are allowable. Whenever possible, staff should be instructed to obtain a complete written or electronic order. If a verbal order must be used, nursing should write it down and then read it back to the provider in order to ensure the correct item and dose is ordered.
Hospitals without bar coding capabilities should institute a mandatory independent double-check by two licensed caregivers to ensure the medications match the order. Unfortunately, in emergent situations when overrides are being used, health care practitioners are more prone to make errors, and the more vulnerable the patient is, the more likely he or she is to be harmed by these errors. The independent double-check is a vital safety step when bar coding has not yet been implemented.
It is impossible to effectively manage overrides without training staff on appropriate procedure. Oftentimes, ADC vendors will provide training programs on how to use the override function correctly. However, each institution needs to make sure users understand the critical distinction of when to use the list and when to wait for an order to be approved by pharmacy before removing the medication. Using scenarios to illustrate these points can be particularly useful for staff. For example, when a physician writes an order for furosemide 40 mg IV stat for pulmonary edema, this is an appropriate use of the override list per our facility’s procedures. However, removing the furosemide for another indication would not be allowed.
Measuring Success and Follow-up
As with any project, measuring success via benchmarks is critically important. The team should review override numbers regularly and have a plan for improving compliance if goals have not been met. As part of our plan, we monitor our override percentage for all orders administered to patients. When we began the project, we wanted the nurses to properly use the medication distribution system and felt that the use of the override tool would be an indication that we were not fulfilling our mission. After research and consultation, we chose a target ceiling of 2% as our goal. We have met our goal and have maintained an override percentage of 0.6% in our medical-surgical units and 1.6% in our ICUs throughout the past four years. Our ADCs provide us with a weekly override report, which is reviewed by the unit director. Any instances of unauthorized overrides are discussed with staff members so the mistake will not recur.
Regular reconciliation of ADC medications removed via the override function and periodic safety checks can help ensure overrides are being used as intended. Limiting the number of medications that can be removed via the override function and carefully reviewing those medications to make sure they are correct can minimize inappropriate overrides. Managing overrides goes more smoothly if both nursing and pharmacy work together to develop effective strategies to address errors in usage. If safety measures uncover staff members who require additional education regarding correct procedures, this reeducation should be promptly provided.
Leroy Kromis, PharmD, BCPS, is the medication safety officer at Lehigh Valley Hospital. Prior to joining Lehigh Valley, Leroy worked as a clinical pharmacist at Duke University Hospital. He obtained his BS in pharmacy and PharmD from the University of North Carolina at Chapel Hill. Leroy has a strong interest in critical care and health care quality, and is a lecturer at DeSales University and serves on the adjunct faculty for Wilkes University and the University of the Sciences in Philadelphia.
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