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PSNet: Patient Safety Network
Journal Article

Assessing and monitoring override medications in automated dispensing devices.

Kowiatek JG, Weber RJ, Skledar SJ, et al. Joint Commission journal on quality and patient safety. 2006;32:309-17.

This medication safety study describes a process to prevent unsafe medication dispensing from automated systems. Investigators evaluated the types and frequencies of medications administered by override, used an expert panel to revise the medication override list, developed a tool for override monitoring, and specifically measured the change in override use of opioids (a high-alert medication class). The authors discuss their multifaceted approach, present examples of the changes that resulted, and offer steps for other organizations interested in similar implementation strategies.