Regionalized Health System Review of Automated Dispensing Cabinet Overrides

Automated dispensing cabinet (ADC) overrides are used to access emergent or urgent medications when time delay from computerized provider order entry may result in patient harm. [1] Although necessary, ADC overrides bypass the safety features of order entry and verification which increase the risk of an error occurring and potential patient harm. To protect patient safety, national organizations such as The Joint Commission and Institute for Safe Medication Practices have called for hospitals to review overriding trends and available medications on override. AdventHealth Central Florida Division - South (CFD-S) met the recommendations to track overrides but there was limited understanding of the data. A quality improvement project was necessary to investigate the division's risk of error and identify interventions to proactively limit patient risk. The initial task of the quality improvement project was to create a standardized ADC override report that could be shared with pharmacy and nursing leaders within AdventHealth CFD-S monthly. As the project progressed, multiple interventions were identified such as standardizing the information reflected in the report, improving education about ADC overrides across multi-disciplinary departments, and critically reviewing the data to identify needed changes within the division. The efforts to share the ADC override metrics across all levels has improved understanding of ADC override goals and intentions of monitoring ADC overrides. This has paved the path to improving ADC override unit culture and identify gaps within the system that allows overrides to occur.