Impact of Optimization of Automated Dispensing Cabinet Profiling on Override Rates in the Emergency Department

Abstract

Background:

Automated dispensing cabinets (ADCs) are widely used in emergency departments (EDs) to enable rapid access to medications. However, use of the override function, which bypasses pharmacist review, has been associated with medication errors and adverse drug events. This quality improvement initiative aimed to reduce unnecessary ADC overrides through implementation of ADC profiling and workflow optimization strategies while maintaining timely medication access in a high-acuity emergency department.

Methods:

This retrospective, single-site, pre–post intervention quality improvement study was conducted at a 950-bed community hospital with a high-volume adult ED. The intervention consisted of a coordinated strategy implemented sequentially and included standardization of the ED ADC formulary, development of a harmonized override medication list limited to time-sensitive therapies, redesign of the electronic health record ordering interface to align with ADC inventory and clinical protocols, and multidisciplinary staff education. Data was collected during a 5-month pre-implementation period from September 2024 through January 2025 and a 3-month post-implementation period from February 2025 through April 2025. The primary outcome was the monthly override rate per ADC. Secondary outcomes included identification of frequently overridden medications and evaluation of medication workflow timing metrics.

Results:

Emergency department override rates declined substantially following implementation. Monthly ED override rates decreased from a pre-intervention range of 12.21% to 16.35% to 1.65% in February 2025, 1.10% in March, and 0.90% in April. Cabinet-level override rates remained below the institutional benchmark of 3%, ranging from 1.2% to 6.8% (median 2.3%) during the first month post-implementation and subsequently 0.3% to 2.2% (median 1.2%) in March and 0.2% to 1.3% (median 0.9%) in April. Overrides involving high-risk medications, including opioids and anxiolytics, declined markedly following implementation. The mean time from medication order entry to pharmacist verification increased modestly from 11 to 13 minutes, and the mean time from pharmacist verification to medication removal increased from 52 to 55 minutes. Review of internal safety reporting systems and operational feedback did not identify medication delays or adverse events attributable to ADC profiling.

Conclusions:

Implementation of ADC profiling supported by formulary standardization, override governance, EHR workflow alignment, and multidisciplinary education significantly reduced override rates in a high-acuity emergency department. These findings demonstrate that pharmacist verification and override restrictions can be integrated into ED medication workflows without compromising timely medication access and provide a practical framework for improving medication-use safety processes in emergency care settings.