Automated dispensing machines (ADM) are a computerized companion technology that reduces labor and contributes to patient safety. When stocked, ADMs store medications and control electronic dispensing. In emergent situations, facilities can approve nursing retrieval of medications prior to pharmacy review via override from the ADM. However, retrieving medications by the override mechanism and administering prior to pharmacy review increases the risk for medication errors. The primary objective of this study was to evaluate the appropriateness of medications removed from the ADM using the override function at a facility owned by Hospital Corporation of America (HCA). The secondary objective was to determine the barcode scan rates of medications removed by the override function. Information was collected to determine which medications were removed from the ADM and the shift, indication, and medication barcode/patient armband scanning rates. Based on medication errors identified, significant changes have been made to the override process, including the number of medications available for override and the requirement of an indication prior to medication removal. Formulary changes were made and opportunities for education identified during the evaluation. This study highlighted an opportunity to embed the culture of patient safety to promote safe medication practices.

Introduction

In February 2000, shortly after the Institute of Medicine’s seminal publication of To Err is Human,¹ Hospital Corporation of America (HCA) began developing electronic medication administration recording (eMAR) and barcoding technology with the goal of improving medication administration safety and fostering a culture of patient safety. eMAR and barcoding represent the use of technology to prevent and detect errors by using data to identify and measure improvements. The implementation of an information technology solution (eMAR) paired with item-specific identification (barcoding) enables the user to administer medications with general confirmation of the Five Rights of Medication Administration: Right Patient, Right Medication, Right Dose, Right Route, Right Time. In addition to these “five patient rights,” the system allows for review of lab values and for allergy/interaction verification. For the successful implementation of the system, the pharmacy was required to barcode all medications at the unit of use or to provide a patient-specific prescription barcode, which is applied to piggybacks, intravenous solutions, and multidose medications. All patients admitted to the facility receive a barcoded armband that is unique to their identity and to that particular hospitalization.

The eMAR and barcoding system uses mobile carts with laptops, tethered barcode scanners, or desktop computers with wireless scanners to read barcode labels on medications and patient armbands. Pharmacy order entry creates the patient’s medication profile, which provides a cross-reference when the medication is scanned. If a medication is required urgently, the system is integrated with the Automated Dispensing Machine (ADM) to display available “override” medications on the patient’s profile. This enables a caregiver to scan the medication and verify the patient’s armband before administering a stat medication that has not been reviewed by the pharmacists.

Objectives

This study was conducted at the Parthenon Pavilion, a psychiatric facility at HCA’s Centennial Medical Center, which utilizes electronic medication barcoding technology. Hospital process calls for physician orders to be reviewed by pharmacy, and then for nursing to procure barcoded medications from the ADM once they are on a patient’s profile. The barcodes from the medication and patient armband are scanned prior to administration of the medication. In urgent/emergent situations, medications can be retrieved prior to pharmacy review, using the override function. Historically, medications were added to the override list because of staff request only.

The Parthenon Pavilion has four automated dispensing machines; each floor has one machine that is used by two units. The medications available for override were not consistent throughout the building. This created a problem because staff frequently floated between the floors. A decision was made to reduce the override medication list to 23 medications and to standardize the override list among the four ADMs (Table 1).

Table 1

Medications available for override at Parthenon Pavilion.

The primary objective of this study was to evaluate the appropriateness of medications removed from the ADM using the override function. The secondary objective was to determine the barcode scan rates of medications and patient verification when medications were removed using the override function.

Methods

The study encompassed all medications removed from the Parthenon Pavilion’s four ADMs using the override function during the period from May 2006 through July 2006. In total, 59 transactions were analyzed retrospectively. The following information was collected from patient medical records: patient sex, diagnosis, and age; medication route; time the medication was reviewed by pharmacy; whether there was a medication error or subsequent adverse drug reaction (ADR); indication for medication administered; and whether the nurse scanned the medication barcode and the patient armband prior to administration.

A medication error was defined using the National Coordinating Council for Medication Error Reporting and Prevention definition as any preventable event that could cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.⁹ ADRs were tracked using the hospital ADR reporting system. Appropriateness of the medication override function was determined by a match between indication and symptomatology and by whether the physician order corresponded to the medication administered. Barcode medication and patient armband scan rates were evaluated for compliance with patient safety technology.

Results

Fifty-nine instances of medication removal via the override function were documented. The patients in this convenience sample had a mean age of 51.65 (±15.37) years. Fifty-nine percent of patients were female; the most common diagnoses were bipolar disorder (N = 17), major depressive disorder (N = 14), schizophrenia (N = 11), and schizoaffective disorder (N = 7).

The most frequently removed medication (N = 19) was lorazepam intramuscular (IM) formulation, followed by haloperidol intramuscular (N = 8), lorazepam oral tablet (N = 7), and nitroglycerin sublingual tablets (N = 6). Other medications removed via the override function included ziprasidone, benztropine, chlorpromazine, aspirin, diphenydramine, lidocaine viscous solution, glucagon, and phenobarbital.

Indications for the medications removed via the override function included: treatment of acute agitation (N = 28), chest pain (N = 8), unknown (N = 6), psychosis (N = 5), extrapyramidal side effects (N = 4), anxiety (N = 3), pruritis, alcohol or benzodiazepine withdrawal, hypoglycemia, seizure, and unscheduled procedure (N = 1 each). Of the 59 instances of override, 17 (28.8 percent) occurred during a first shift (7:00 am to 3:30 pm); 31 (52.5 percent) occurred during a second shift (3:00 pm to 11:30 pm); and 11 (18.6 percent) occurred during a third shift (11:00 pm to 7:00 am). Forty-five overrides (76.3 percent) occurred on weekdays. The hospital pharmacy was staffed 24 hours per day, 7 days per week.

Of the 59 override transactions, 50 were appropriate according to the match between symptoms and the medications’ listed indications. Medication errors occurred with nine of the transactions: three administrations had no documented physician order; one involved the wrong route; in two instances, the wrong medication was given; and two patients received the wrong dose. In addition, one patient received lorazepam despite the generation of an allergy warning to this medication. Lorazepam and haloperidol were the most common psychiatric medications administered by override, most commonly in response to agitation or psychotic behavior. The barcoding scanning rates for the 59 transactions were 62.7 percent for the medications and 57.6 percent for the patient armbands.

The largest number of overrides occurred during the second shift, which was also when the majority of patients were admitted. Medications removed via override were used appropriately in 85 percent of instances. Nine override occurrences resulted in administering medications inappropriately. The lorazepam administration error did not result in an adverse event for the patient, since the allergy was disputed in the patient record. Based on the low scan rates identified in this study, the barcoding system was not used to its full patient safety potential during emergent situations. The average scan rate for both medications and patient armbands was 97.0 percent, compared to the 62.7 percent for medications and 57.6 percent for armbands during emergent overrides.

In six instances, the appropriateness of medication use could not be assessed because there was no documentation explaining why the medications were given. Antipsychotics were commonly removed via override and were also commonly associated with a wrong medication, wrong route, or wrong dose error. Agitation followed by chest pain were the most common symptoms associated with medications being removed via the override function. Scan rate compliance was lower for medications removed via override.

Based on medication errors identified, significant changes were made to the override process, including decreasing the number of medications available for override and adding the requirement of an indication prior to removal of medication (Table 2). Formulary changes were also made. Olanzapine IM was removed from the formulary to decrease the risk of the wrong medication being given for acute agitation.

Table 2

Approved AcuDose-Rx^® indications for override.

Educational opportunities were identified during the evaluation, specifically the need for differentiation between chest pain and panic attacks. This study highlighted an opportunity to embed the culture of patient safety. By educating staff and helping them recognize the benefits of using scanning technology to prevent errors, we hope to decrease the number of system bypasses and increase the scan rates.

Discussion

This study demonstrated a wide variety of reasons for using the override function for retrieving medications from ADM. The high rates of complications in this situation suggest a need for greater control of utilization, while preserving rapid access for genuine emergency situations.

This study confirmed that, even with barriers in place, there was still a potential for inappropriate use of medications removed via the override function. Limiting override access could decrease medication errors and improve patient safety throughout the hospital.

Centennial Medical Center initiated review of all medications that were removed via the override function to evaluate for appropriateness of use. HCA’s medication safety team is now sharing this learning throughout its more than 300 facilities, providing guidance to reduce the number of medications available for override and education to the staff regarding the appropriate use of the override function. The medication safety team is also reinforcing the importance of utilizing the electronic medication barcoding technology, especially in the “override” situation.

Organizations using ADM should establish usage and access requirements and regularly reconcile medications that have been removed via the override function. Periodically, safety checks should be conducted to ensure that the devices are being used and maintained as intended. These would include periodic “checks” to validate medication placement accuracy—checking presence, absence, and appropriate dose—within the specified compartments of the device.

Pharmacy departments should work with nursing departments to develop effective policies and procedures that address potential sources of error in order to prevent ADM errors. Establishing a limited selection of medications that can be removed via the override function and diligently reviewing the medication being accessed via the override function could help reduce medication errors. Requiring that pharmacy review and verify the appropriateness of all orders for medications prior to their administration, except when such a review might cause a medically unacceptable delay, should help decrease the number of medications that are removed via the override function. For a successful implementation of eMAR and barcoding, it is imperative to understand and follow the built-in safety triggers.

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