Errors associated with medications removed from automated dispensing machines using override functions.
Approach to Improving Safety
Setting of Care
This study evaluated 470 medication overrides in demonstrating that most errors occur in settings when all medications were available for removal as opposed to when only select medications were available (eg, emergency, pre-procedure, and pain medications). Investigators from this single hospital study determined that nearly 90% of the overrides were correctly administered and that the large majority of variances were due to missing documentation for the medication overridden followed by an incorrect medication or dose administered. A past study assessed and monitored override medications in automated dispensing devices whereas a previous review discussed a similar issue of overriding drug safety alerts but in computerized physician order entry (CPOE) systems.