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

Automated dispensing cabinet (ADC) medication overrides can contribute to increased risks of drug diversion, medication errors, and waste. To reduce ADC overrides, a multidisciplinary process improvement initiative was conducted over 3 years to identify, evaluate, and monitor medication overrides, with an initial goal of quarterly 5% reductions in the override rate.

Lean Six Sigma process improvement methodology identified the root causes of inappropriate medication overrides. Through a series of interventions, both targeted and institution wide, the process improvement initiative addressed technological, process, and cultural root causes. The only clinical units excluded in this project were intraoperative areas. Targeted interventions included automated pharmacy dispensing of high-use as-needed medications and correction of interface errors between the ADC and electronic health record. System-wide interventions included updating ADC override reasons to align with policy, implementation of an approved medication override list, education, data transparency, and linking ADC override pulls to the medication administration record. The rate of overrides decreased from 6.18% at baseline to 4.41% during the initial phase of targeted interventions (29% reduction from baseline; P < 0.001), with continued improvements following organization-wide interventions to achieve an override rate of 2.13% by the control phase (65% reduction from baseline; P < 0.001). No preventable adverse drug events related to initiative changes were reported during the study period.

Through utilization of Lean Six Sigma methodology and involvement of a multidisciplinary process improvement team, the initiative achieved a significant and sustained reduction in the rate of medication overrides.