Analyzing override patterns in profiled automated dispensing cabinets at a tertiary care hospital in Saudi Arabia

Background

Inappropriate automated dispensing cabinet (ADC) overrides pose a significant risk to patient safety. Bypassing pharmacist review during these overrides removes a vital safety check, leaving nurses to review complex medication orders alone. This can lead to overlooking incorrect orders and significantly increasing the potential for medication errors. While Institute for Safe Medication Practices (ISMP) guidelines promote profiled ADCs and safe override practices, there is no national standard for acceptable override rates.

Objectives

Assessing the appropriateness of ADC overrides of profiled ADCs at a tertiary hospital in Saudi Arabia in accordance with ISMP guidelines (third core safety process).

Methods

This retrospective observational study reviewed all override transactions for 13 profiled ADCs over a 3-month period, from 1 October 2022 until 31 December 2022. The target override rate was set at no more than 5%. After applying exclusions, the relevant data fields were extracted from electronic records of 2 integrated systems: the Omnicell dashboard and the BESTCare hospital information system. The study assessed whether the override transactions complying with the standard elements required for appropriate ADC overrides in accordance with ISMP recommendations and hospital regulations.

Results

Six hundred sixty-four override transactions from profiled ADCs were reviewed and evaluated. Although the overall override limit for profiled ADCs was met (1.9%), multiple inappropriate override practices were revealed. These inappropriate practices are missing physician orders (33.7%), undocumented verbal orders (31.5%), nonurgent physician orders (11%), missing (8.4%) or delayed (33.7%) administration records, and unrecognized override errors (5.3%). Only 3 (0.5%) met all the standard elements required for ADC overrides.

Conclusion

The target override threshold of 5% is inadequate to demonstrate sufficient adherence to the standard elements of appropriate overrides or effectively prevent medication errors. Consequently, a significantly lower target threshold override limit, well below 5%, should be considered, especially with 24-hour pharmacy services and fully integrated computerized physician order entry with ADC system. A multidisciplinary override surveillance team is considered essential.