Medication Overrides Pose Much Higher Level of Risk
Automated dispensing cabinets (ADCs) allow ED medications to be stored and issued electronically at the point of care. “This allows for a dramatic reduction in the time from prescribing to medication administration, which is particularly advantageous in the ED setting,” according to Kyle Weant, PharmD, BCPS, BCCCP, FCCP, an emergency medicine clinical pharmacy specialist at the University of South Carolina.
ADCs offer safeguards that older medication cabinets or carts used for this purpose did not, such as allowing for pharmacist verification of orders before removal and interactive computerized warnings when the medication is accessed. “However, errors can still occur,” Weant warns.
Nurses still can select the wrong medication or dose. EDs might make restocking errors, placing medications in the wrong location. Guidelines for the safe use of ADCs have been developed by the Institute for Safe Medication Practices and the American Society of Health-System Pharmacists.1,2 “To facilitate care in emergent situations in the ED, specific medications are placed on an override status,” Weant notes.
This allows those drugs to be removed for any patient at any time, without a written order from a prescriber or review by a pharmacist. “This is an essential mechanism to ensure optimal patient care,” Weant says. “However, it does come with a much higher level of risk of the wrong medication being removed and administered.”
There are many ways to limit the potential for errors. Using cautionary messages on screens during the removal process allows an opportunity for reassessment. Segregate agents that pose particularly high risks (e.g., neuromuscular blockers) from regular stock via lidded containers or isolated storage areas. Place auxiliary labels alerting the user to unique characteristics (e.g., “Warning: Paralyzing Agent — Causes Respiratory Arrest.”).
Additionally, staff could reconfigure ADCs to allow for simultaneous searching by brand and generic name. Design the environment surrounding ADCs to limit distractions during searches and medication removal. Also, use barcode scanning before medication administration. “This provides for a secondary double-check that the appropriate medication has been removed from the ADC,” Weant explains.
Overall, there should be a regular review of the list of agents available to be overridden (to evaluate the continued need to be on that list), conducted by a multidisciplinary team of ED prescribers, nurses, and pharmacists.
“They should also regularly review those medications that are frequently being overridden to ensure that it is occurring for the appropriate emergent situations,” Weant concludes.
REFERENCES
- Institute for Safe Medication Practices. ISMP Targeted Medication Safety Best Practices for Hospitals. 2022.
- [No authors listed]. ASHP guidelines on the safe use of automated medication storage and distribution devices. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1998;55:1403-1407.