Medication overrides: Decreasing risk through process improvement in a pediatric health system

Area of Science:

• Healthcare quality improvement
• Pharmacy practice
• Patient safety

Background:

• Automated dispensing cabinets (ADCs) are essential for medication management but overrides increase risks of drug diversion, errors, and waste.
• A multidisciplinary approach is needed to address the complexities of ADC overrides.

Purpose of the Study:

• To reduce medication override rates in automated dispensing cabinets (ADCs).
• To identify and address the root causes of inappropriate ADC medication overrides.
• To achieve a sustained reduction in ADC override rates through process improvement.

Main Methods:

• Utilized Lean Six Sigma methodology for process improvement.
• Conducted a 3-year initiative involving a multidisciplinary team.
• Implemented targeted interventions (e.g., automated dispensing, EHR corrections) and system-wide changes (e.g., policy updates, education, data transparency).

Main Results:

• The medication override rate decreased from 6.18% at baseline to 2.13% in the control phase, a 65% reduction (P < 0.001).
• Initial targeted interventions resulted in a 29% reduction in override rates (P < 0.001).
• No preventable adverse drug events related to the initiative were reported.

Conclusions:

• Lean Six Sigma methodology effectively identified root causes of medication overrides.
• A multidisciplinary process improvement initiative achieved significant and sustained reductions in ADC medication override rates.
• Interventions addressed technological, process, and cultural factors contributing to overrides.