'Overriding' patient safety features of medication-use technologies: 5 study findings

One area of patient safety that is rarely talked about is idea of minimizing overrides on medication alerts for automated dispensing cabinets, according to recent research from the Pennsylvania Safety Authority in Harrisburg, summarized by Healthcare Risk Management.

The research was conducted by Matthew Grissinger, manager of medication safety analysis for PSAH. Mr. Grissinger set out to discover how often healthcare workers override the safety features incorporated in medication-use technologies meant to warn about possibly unsafe conditions or errors.

He examined 583 overrides submitted to the Pennsylvania Patient Safety Reporting System from January 2013 to December 2014.

Highlighted below are five findings from his research.

1. Automated dispensing cabinets account for the most overrides on medication alerts, at 70 percent, followed by computerized prescriber order entry at 8.2 percent and bar-code medication administration devices at 7.5 percent.

2. The most common override is for unauthorized medication, and more than one-quarter (26.4 percent) of overrides involved a high-alert medication.

3. Antibiotics and opioids each accounted for 12 percent of overrides, followed by anticoagulants, at 7.4 percent.

4. Despite expectations, less than one-quarter of the reports came from intensive care units and emergency departments. Instead, overrides occurred most often in medical-surgical units.

5. The majority of the reports involved elderly patients (65 years or older); only 5.5 percent involved a pediatric patient.

According to Mr. Grissinger, considering the patient safety implications of overrides is important because this technology has exploded in healthcare over the last decade.

"You're always going to have alerts and overrides, but with some technology like computerized order entry, a lot of the alerts aren't meaningful," said Mr. Grissinger. "When people see so many alerts that aren't meaningful, they get in the habit of overriding them almost automatically, and that's when something terrible can happen because they override the alert that was significant and meaningful."

To ensure overrides aren't compromising patient safety, the study author suggested having risk managers monitor alerts and overrides on a monthly basis, investigate how and why overrides occur and identify who is overriding the alerts. Using hard stop alerts is another solution, though they should only be used in extreme circumstances.



More articles on patient safety:
The chronic problem of communication: Why it's a patient safety issue, and how hospitals can address it
8 Michigan hospitals earn EAM patient safety awards
athenahealth adds patient safety to employee training in 2016

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