Errors Associated with Medications Removed from Automated Dispensing Machines Using Override Function

Abstract

Automated dispensing machines (ADM) are used in many US hospitals. Nurses are often permitted to remove some medications by using an override function if pharmacists have not yet entered orders for the medications. We reviewed 470 overridden medications to determine whether the medications were removed in accordance with written orders. Fifty-five (11.7%) overridden medications involved variances with written orders, including 47 (85.5% of variances) involving routine orders not appropriately documented, and eight variant removals (14.5% of variances) involving medication errors or near misses. The eight variant removals involved oral medications that were available only when pharmacy staff was not present and all medications were retrievable on override. Errors made when removing medications from ADMs using an override function were more likely when all medications were available for removal, as opposed to when only emergency, pre-procedure, and IV pain medications were available.