Christine D. Franciscovich MSN, CRNP, NNP-BC (is the Patient Safety and Improvement Advanced Practice Provider, Children's Hospital of Philadelphia.), Anna Bieniek BS, PharmD, MS (is the Pharmacy Regulatory Compliance, Quality Assurance, and Medication Safety Program Manager, Children's Hospital of Philadelphia.), Katie Dunn BSN, RN, CPN (is a Certified Pediatric Nurse, Children's Hospital of Philadelphia.), Ursula Nawab MD (formerly Senior Medical Director of Patient Safety, Children's Hospital of Philadelphia, is Chief Patient Safety and Quality Officer, Johns Hopkins All Children's Hospital. Please address correspondence to Christine D. Franciscovich)
{"title":"Reducing Automated Dispensing Cabinet Overrides in the Perianesthesia Care Unit: A Quality Improvement Project","authors":"Christine D. Franciscovich MSN, CRNP, NNP-BC (is the Patient Safety and Improvement Advanced Practice Provider, Children's Hospital of Philadelphia.), Anna Bieniek BS, PharmD, MS (is the Pharmacy Regulatory Compliance, Quality Assurance, and Medication Safety Program Manager, Children's Hospital of Philadelphia.), Katie Dunn BSN, RN, CPN (is a Certified Pediatric Nurse, Children's Hospital of Philadelphia.), Ursula Nawab MD (formerly Senior Medical Director of Patient Safety, Children's Hospital of Philadelphia, is Chief Patient Safety and Quality Officer, Johns Hopkins All Children's Hospital. Please address correspondence to Christine D. Franciscovich)","doi":"10.1016/j.jcjq.2024.08.006","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>Automated dispensing cabinets (ADCs) are used to store and dispense medications at the point of care. Medications accessed from an ADC before pharmacist order verification are removed using override functionality. Bypassing pharmacist verification can lead to medication errors; therefore, The Joint Commission considers overrides acceptable only in limited scenarios. During an 18-month period, the override rate in our perianesthesia care unit (PACU) was 17%, with oral midazolam accounting for roughly 40% of overrides. A multidisciplinary quality improvement (QI) project was initiated with a goal to reduce overrides by 10% (17% to 15%) by December 31, 2021.</div></div><div><h3>Methods</h3><div>Key drivers for reducing overrides included timely medication order entry, nursing practice to wait for verification, and timely pharmacist medication order verification. Interventions related to the latter two drivers included nursing education, individual interviews, and a workflow change involving nurse-to-pharmacy communication prior to medication overrides. Interventions were implemented in three Plan-Do-Study-Act cycles beginning in July 2021. Outcome metrics were average monthly percentage of total medication overrides and overrides for oral midazolam, which were analyzed using statistical process control charts.</div></div><div><h3>Results</h3><div>Following interventions, the average monthly percentage of total medication overrides decreased from 17% to 8% in July 2021, and further to 4% in February 2022. Oral midazolam overrides decreased from 22% to 9% in July 2021, and further to 3% in February 2022.</div></div><div><h3>Conclusion</h3><div>Both total and oral midazolam overrides were reduced by changing nursing and pharmacy workflow. Reducing ADC overrides is a complex process balancing operational flow and safety efforts.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 12","pages":"Pages 867-876"},"PeriodicalIF":2.3000,"publicationDate":"2024-08-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Joint Commission journal on quality and patient safety","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S1553725024002605","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
引用次数: 0
Abstract
Background
Automated dispensing cabinets (ADCs) are used to store and dispense medications at the point of care. Medications accessed from an ADC before pharmacist order verification are removed using override functionality. Bypassing pharmacist verification can lead to medication errors; therefore, The Joint Commission considers overrides acceptable only in limited scenarios. During an 18-month period, the override rate in our perianesthesia care unit (PACU) was 17%, with oral midazolam accounting for roughly 40% of overrides. A multidisciplinary quality improvement (QI) project was initiated with a goal to reduce overrides by 10% (17% to 15%) by December 31, 2021.
Methods
Key drivers for reducing overrides included timely medication order entry, nursing practice to wait for verification, and timely pharmacist medication order verification. Interventions related to the latter two drivers included nursing education, individual interviews, and a workflow change involving nurse-to-pharmacy communication prior to medication overrides. Interventions were implemented in three Plan-Do-Study-Act cycles beginning in July 2021. Outcome metrics were average monthly percentage of total medication overrides and overrides for oral midazolam, which were analyzed using statistical process control charts.
Results
Following interventions, the average monthly percentage of total medication overrides decreased from 17% to 8% in July 2021, and further to 4% in February 2022. Oral midazolam overrides decreased from 22% to 9% in July 2021, and further to 3% in February 2022.
Conclusion
Both total and oral midazolam overrides were reduced by changing nursing and pharmacy workflow. Reducing ADC overrides is a complex process balancing operational flow and safety efforts.