SCIENCE AND PRACTICE

Journal of the American Pharmacists Association 63 (2023) 193e197

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BRIEF REPORT
Practical strategies for ensuring safety of medication overrides
from automated dispensing cabinets
Karen V. Youmbi*, Amisha Arya, Ashley Conger, Domini Hood, Jennifer Mai,
Sheetal Patel-House, Michelle Then

a r t i c l e i n f o a b s t r a c t

Article history: Background: The Institute of Safe Medication Practices (ISMP) and American Society of Health-
Received 20 January 2022 System Pharmacists (ASHP) have made recommendations on the judicious use of the override
Accepted 22 September 2022 feature on automated dispensing machines including guidelines for the creation of safety
Available online 11 October 2022
protocols, security, and decision support, yet it remains unclear how health care organizations
(HCOs) have been able to implement these recommendations and what metrics are used to
monitor safety and compliance.
Objectives: This study aimed to assess and compile medication override practices and metrics
used by HCOs to ensure medication safety and regulatory compliance.
Methods: Using the ISMP and ASHP’s guidelines on medication overrides, a survey was
developed and distributed to organizations to understand their approach and processes sur-
rounding medication overrides.
Results: Thirty organizations responded, with 93.3% (28/30) reporting having a medication
override policy. A standard override rate was not evident, but 46.7% (14/30) shared a rate of 5%
or less. Two-thirds of respondents identified the medication safety committee or its members
as being responsible for reviewing the list of overridable medications, with over half stating
that this review occurs annually. Furthermore, 80% (24/30) of organizations described a
retrospective process used to review individual medication overrides daily, monthly, or at a
lower frequency using reports from the automated dispensing cabinet, the electronic health
records, pharmacist review of associated orders, or a combination of the three. Although every
participant has implemented at least one of the recommended practices in the ISMP and ASHP
guidelines, standard practices and benchmark data surrounding acceptable override rates
remain unclear.
Conclusion: This survey provided insight into current processes used in various organizations
to safely manage medication overrides. Its results can be used by institutions to optimize their
processes. Information from a larger number of organizations is needed to establish standard
best practices and benchmark metrics.
© 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Background
In 2018, The Joint Commission (TJC) updated their medi-
cation management standards to include a requirement for
hospitals that use automated dispensing cabinets (ADCs) to
have a policy describing the types of medication overrides
Disclosure: The authors declare no relevant conflicts of interest or financial
relationships.
* Correspondence: Karen V. Youmbi, PharmD, BCPS, Associate Director -
Pharmacy Services, Cedars-Sinai Medical Center, 8700 Beverly Blvd., 1165W,
Los Angeles, CA 90048.
E-mail address: karen.youmbi@cshs.org (K.V. Youmbi).
reviewed and the frequency of the review.1 Health care orga-
nizations (HCOs) were challenged to ensure that their pro-
cesses were robust enough to meet the new standards while
ensuring medication safety.
An ADC is a computerized medication dispensing device
utilized in health care settings. They allow medications to be
stored and dispensed near the point of care while controlling
and tracking drug distribution. ADCs can be set to a profiled
status, which requires withdrawals from the machine to be
associated with a patient profile, or unprofiled status, where
withdrawals are not patient-specific. The profiling function of
ADCs ensures that only intended medications for each patient
are made available: the order must be electronically placed by

https://doi.org/10.1016/j.japh.2022.09.015
1544-3191/© 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE
K.V. Youmbi et al. / Journal of the American Pharmacists Association 63 (2023) 193e197
the provider and verified by a pharmacist before a medication
is available for retrieval. Override functionality allows a clini-
cian to remove a medication from the cabinet before the
electronic order is placed and verified. The intent of the
override function is to allow access to medications in urgent or
emergent situations. To close the regulatory and safety loop,
after the emergent medication administration, the provider
must input a retroactive electronic order, and the adminis-
tration may be linked electronically to the order. There are
many benefits that can result from employing a strong over-
ride process as part of a profiled ADC workflow. However, the
benefits of medication accessibility must be balanced with the
risk of removing safety elements and regulatory compliance.
Objective
Organizations such as the Institute of Safe Medication
Practices (ISMP) and American Society of Health-System
Pharmacists (ASHP) have published best practice recommen-
dations on the judicious use of the override feature including
guidelines for the creation of safety protocols, security, and
decision support,2e5 yet it remains unclear how HCOs have
been able to implement these recommendations and what
metrics are used to monitor safety and compliance. This survey
aimed to assess and compile medication override practices
and metrics used by HCOs to ensure medication safety and
regulatory compliance.
Methods
The Quality, Safety, and Compliance Committee (QSC)
within the Academic Medical Center Pharmacy Network of
Vizient, a member-driven health care performance improve-
ment company comprising of a range of HCOs across the
nation, identified the need to provide practical strategies for
incorporating the recommendations from ISMP and ASHP to
best manage the ADC override feature. To understand in-
stitutions’ current practices around the safe management of
medication overrides, a subcommittee of the QSC collected
information on override use and management from various
HCOs through a survey with 25 close-ended questions, pro-
vided in Appendix 1. For each question, members were asked
to select options that best categorized their institution’s
approach to selection of medications for override, metrics used
to track and trend medication overrides for appropriateness of
use, and overall process used to monitor overrides.
The questionnaire was developed based on published
guidelines from ISMP and ASHP following The Tailored Design
Method (TDM) for mail and Internet surveys.2e6 The survey
consisted of 4 sections that captured the following informa-
tion: baseline institution information from each participant;
availability of internal guidance documents, for example,
policies for appropriate usage of medications on override;
committee oversight and criteria used to approve medications
for override; and metrics and reporting tools used to track and
trend medication overrides for appropriateness. The survey
was created using the Qualtrics XM survey tool (Qualtrics) and
was reviewed by the study team but not pretested before
194
release. No incentives were provided for completing the
survey.
The survey was initially released via e-mail as well as a
posted link to a respondent pool of 78 individual partici-
pants for a 2-week period with one reminder sent out after
the first week. It was then released using the same distri-
bution method to a larger respondent pool of 503 HCOs for
an additional two weeks with a reminder sent after the first
week. Responses were gathered from the 4-week period,
and survey results were exported into Microsoft Excel
(Microsoft) for analysis and removal of duplicate responses
to determine elements of best practices for safe manage-
ment of medication overrides.
Results
The survey was shared with 503 HCOs and received re-
sponses from 30 organizations, resulting in a response rate of
6%. Eighty percent of respondents (24/30) reported having
greater than 500 patient beds. Twenty-two responding HCOs
used Epic (Epic Systems) as their Electronic Health Record
(EHR). Cerner (Oracle Cerner) and AllScripts (Constellation
Software) were used by 16.6% and 6.7% of HCOs, respectively
(Table 1).
Of the respondents, 19 (63.3%) reported having greater than
150 ADCs, and 5 (16.7%) reported having 100-150 ADCs. The
majority (56.7%) of respondents reported that less than 25% of
their ADCs were nonprofiled whereas 7 (23.3%) respondents
reported that 25%-50% of their ADCs were nonprofiled. ADC
overrides were permitted in various settings including inpa-
tient areas, emergency departments (EDs), operating rooms,
postanesthesia care units (PACUs), and procedural areas.
Twenty-eight HCOs (93.3%) reported having a policy in place
for ADC overrides, with 29 HCOs reporting having a process or
policy in place for ADC overrides that occur during downtime
specifically (Table 1).
Survey respondents were also asked about various override
rates defined as the percentage of medications removed from
ADC using the override functionality. Fifteen HCOs shared
their institution-wide override rate, with 9 of them disclosing
a rate of 3% or less. Six HCOs reported a rate of 5% or less. There
were 6 HCOs that shared their intensive care unit (ICU) over-
ride rates. The ICU override rate varied across respondents and
ranged from 3.5% to less than 10%. Seven HCOs reported
override rates for their medicine units, which was less than 3%
in over 85% of HCOs. The ED rates varied from 3% to 7% equally
across the 3 organizations that provided this metric. Fifty
percent of the 6 respondents who provided their override rate
in the surgical units have a rate of 1% or less whereas 33.3%
reported an override rate of less than 3%. Overall, 5 of the 30
HCOs that responded to the survey indicated that they do not
have established benchmarks or monitor override rates
routinely (Table 2).
Twenty of the 30 respondents (60.7%) disclosed that they
review their override list on an annual basis whereas 20% (6/
30) only reviewed their list as needed. The medication safety
committee or specific members of that committee, such as the
medication safety pharmacist or nurse, are responsible for
maintaining the override list in 80% (24/30) of the institutions.
 SCIENCE AND PRACTICE
Safety of medication overrides

Table 1 Table 1 (continued )

Demographics of the 30 surveyed HCOs
Question Options Number (%)
Question Options Number (%) Not reviewed 1 (3.3)
Patient beds in < 100 2 (6.7) Categories of medication All medications 14 (46.7)
organization overrides reviewed
100e350 1 (3.3) Controlled substances 5 (16.7)
351e500 3 (10) Controlled substances and 1 (3.3)
> 500 24 (80) hazardous medications
Electronic health record Allscripts 2 (6.7) Controlled substances and 2 (6.7)
used in organization high-alert medications
Cerner 5 (1.7) Controlled substances, 1 (3.3)
Epic 22 (73.3) high-alert medications,
Meditech 1 (3.3) narrow therapeutic index
ADCs in organization < 10 2 (6.7) medications, and top
10e49 0 overridden medications
50e99 0 Controlled substances, 1 (3.3)
high-alert medications,
100e150 5 (16.7)
hazardous medications, and
> 150 19 (63.3)
narrow therapeutic index
Unknown 4 (13.3)
medications
Percentage of < 25% 17 (56.7)
High-alert medications 1 (3.3)
nonprofiled ADCs
No categories established 3 (10)
25%e50% 7 (23.3)
Top overridden 1 (3.3)
51%e75% 5 (1.7)
medications
> 75% 1 (3.3)
Unmatched overrides 1 (3.3)
Institutional policy for Yes 28 (93.3)
Method for capturing ADC reports 9 (30)
overrides
overrides
No 2 (6.7)
ADC reports and EMR 3 (10)
Institutional policy for Yes 29 (96.7)
reports
overrides during
ADC reports, EMR reports, 4 (13.3)
downtime
and pharmacists review in
No 1 (3.3)
real time
Settings in which Inpatient areas only 14 (46.7)
ADC reports and 3 (10)
overrides are allowed
pharmacists review in real
Inpatient areas and 3 (10)
time
ambulatory care centers
EMR reports 4 (13.3)
Inpatient areas and licensed 4 (13.3)
EMR reports and 3 (10)
clinics
pharmacists review in real
Inpatient areas, ambulatory 9 (30)
time
care centers, and licensed
Pharmacists review in real 3 (10)
clinics
time
Frequency of override Daily (controlled 1 (3.3)
Power BI reporting 1 (3.3)
list review substances only)
Monthly 1 (3.3) Abbreviations used: ADC, automated dispensing cabinet; EMR, Electronic
Semiannually 2 (6.7) Medical Record; HCO, health care organization.
Annually 20 (60.7)
As needed 6 (20)
Responsible party for Committee of 1 (3.3)
reviewing override pharmacist(s), nursing, and The following criteria were used to determine which medi-
list risk management cations would be accessible through override: 1) emergent use
Pharmacy Leadership 2 (6.6)
where delay in pharmacist verification could lead to potential
Medication Safety 24 (80)
Committee (may consist of
patient harm, 2) when a licensed independent practitioner
pharmacists, pharmacy controls the ordering, preparation, and administration of the
leadership, nursing medication, or 3) medication error potential (based on internal
leadership, and/or or external reports).
physicians)
Eighty percent (24/30) of responding organizations that
Override Committee 1 (3.3)
Pharmacy and Therapeutics 2 (6.6)
shared their processes reported performing a retrospective
Committee review of override transactions to ensure safety on a daily (n ¼
Frequency of reviewing Daily 11 (36.7) 11), weekly (n ¼ 2), monthly (n ¼ 6), or quarterly (n ¼ 4) basis
retrospective override using ADC reports, EHR reports, pharmacist verification of
reports
medication orders associated with overrides, or a combination
Daily and monthly 2 (6.7)
of the three. Some organizations also reported reviewing
Daily and quarterly 1 (3.3)
Weekly 2 (6.7) overrides at either a lower frequency or a combination of
Monthly 6 (20) frequencies listed in the survey. Over 46% (14/30) of survey
Monthly and quarterly 1 (3.3) participants review all medications removed on override,
Quarterly 4 (13.3) whereas the others focus solely on targeted medication cate-
Quarterly and semiannually 1 (3.3) gories such as controlled substances, high-alert, hazardous,
Annually 1 (3.3)
narrow therapeutic index, or a combination of those
(continued on next page) mentioned.

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SCIENCE AND PRACTICE
K.V. Youmbi et al. / Journal of the American Pharmacists Association 63 (2023) 193e197

Table 2 elements of the TDM in our survey methodology such as

Override rates of surveyed HCOs minimizing nonresponse errors, ensuring clear question
ADC location Override Number of wording, and placing importance on survey brevity, we did not
rates, % hospitals (%) fully implement the methodology. This partial incorporation
Institution-wide (n ¼ 15) <1 2 (13.3) may have led to variation in survey question interpretation.
 1 to  3 7 (46.7) Based on the information obtained from survey re-
> 3 to < 5 6 (40) spondents, best practice recommendations that organiza-
ICU (n ¼ 6) <3 1 (16.7)
tions should consider include implementation of an
 3 to < 5 2 (33.3)
 5 to < 7 2 (33.3) override policy; striving to perform a review of their over-
 7 to < 10 1 (16.7) ride data daily or as frequently as possible, to ensure
Medicine (n ¼ 7) <1 3 (42.8) medication safety and regulatory compliance; identifying
 1 to  3 3 (42.9) their institution’s baseline override rate and selecting a
> 3 to < 5 1 (14.3) reasonable override reduction goal from baseline, if indi-
Surgical units (n ¼ 6) 1 3 (50)
cated, based on their institution’s operations, resources, and
> 1 to < 3 2 (33.3)
 3 to < 5 1 (16.7)
overall feasibility; leveraging their medication safety com-
Perioperative areas (n ¼ 2) <3 1 (50) mittee(s) to oversee override rates and processes; and
 3 to < 5 1 (50) conducting an annual review of the override list and policy,
Emergency department (n ¼ 3) 3 1 (33.3) at a minimum.
> 3 to < 5 1 (33.3)
 5 to < 7 1 (33.3)
Override rate of controlled < 0.5 1 (33.3) Conclusion
medications only (n ¼ 3)
 1.5 to  2 1 (33.3) Results of this survey indicate that the majority of in-
> 2 to < 5 1 (33.3) stitutions that responded have aligned their ADC override
Abbreviations used: ADC, automated dispensing cabinet; HCO, health care management to incorporate at least one of the best practices
organization; ICU, intensive care unit. cited by ISMP and ASHP, which are also key elements of the
standards set forth by TJC.1 In light of recent safety events
Discussion
surrounding the safety of medication overrides during routine
patient care, it is clear that organizations should strive to
As regulatory bodies such as TJC started focusing on ADC
implement as many of those best practices as possible to
override processes, there has been an increased push to
ensure safe use of medication overrides.7
establish best practice guidance and benchmarking data. Na-
Without enough quantifiable data, it is crucial for HCOs to
tional organizations such as ISMP and ASHP suggest a variety
continue sharing their practices to facilitate identification of
of best practices surrounding the processes and governance
benchmark metrics and develop practical best practices to
structure of ADC overrides.1e5 Of those, the need for an orga-
optimize management of ADC overrides.
nizational policy, a limited override list, interdisciplinary re-
view of override data for appropriateness, and periodic review
of these items are the most prominent. References
On the basis of the results of our survey, all respondents
1. The Joint Commission hospital accreditation requirements, medication
have implemented at least one ISMP or ASHP best practice, but management MM.08.01.01 EP 16. The joint Commission©. Last Revised.
only 43% of respondents have incorporated all best practices 2021. https://e-dition.jcrinc.com/MainContent.aspx. Accessed July 20,
into workflows and governance structures. 2021.
2. Institute for Safe Medication Practices. Guidelines for the safe use of
Almost all institutions reported having a policy regarding automated dispensing cabinets. Available at: https://www.ismp.org/.
ADC overrides, allowing overrides in acute care areas, and have Accessed July 20, 2021.
established an institution override rate threshold. Among 3. Traynor K. Joint Commission eyes overrides of dispensing cabinets. Am J
Health Syst Pharm. 2018;75(9):e172ee173.
those with policies, 77% of the institutions stated that their
4. Institute for Safe Medication Practices. Over-the-top risky: overuse of ADC
policy undergoes periodic review at a minimum of once a year. overrides, removal of drugs without an order, and use of non-profiled
In addition, roughly 90% of respondents reported that cabinets. Available at: https://www.ismp.org/. Accessed July 20, 2021.
5. American Society of Health-System Pharmacist Practice Resource for
metrics related to ADC overrides are reviewed by an inter-
Automated Dispensing Cabinet Overrides. https://www.ashp.org/.
disciplinary committee, such as the medication safety or Accessed July 20, 2021.
pharmacy and therapeutics committee. However, metrics are 6. Dillman D, Smyth J, Christian L. Internet, Mail, and Mixed-Mode Surveys: the
reviewed on a quarterly or more frequent basis in only 57% of Tailored Design Method. New York, NY: Wiley; 2009.
7. Institute for Safe Medication Practices. Criminalization of human error and
the cases. Although there is no clear expectation for periodic a guilty verdict: a travesty of justice that threatens patient safety. Available
review, longer time periods between reviews can propagate at: https://www.ismp.org/resources/criminalization-human-error-and-
difficulties to identify clinical, safety, and systems improve- guilty-verdict-travesty-justice-threatens-patient-safety. Accessed June 29,
2022.
ment opportunities.
There were several limitations to this study, with the major Karen V. Youmbi, PharmD, BCPS, Associate Director, Pharmacy Administration,
Cedars-Sinai Medical Center, Los Angeles, CA
limitation being the low response rate. Contributing factors to
the low response rate include the time frame, which spanned Amisha Arya, PharmD, BCSCP, CJCP, Director of Pharmacy, Regulatory and
Compliance, Department of Pharmacy, NYU Langone Health, New York, NY
holidays and the coronavirus disease 2019 vaccine roll-out;
lack of a targeted audience as the survey was distributed to Ashley Conger, PharmD, Clinical Pharmacy Specialist, Department of Pharmacy,
University Hospitals Portage Medical Center, Ravenna, OH; and Assistant Pro-
the entire Vizient Pharmacy network; and a lack of incentive fessor of Pharmacy Practice, College of Pharmacy, Northeast Ohio Medical Uni-
for responding to the survey. Although we incorporated most versity, Rootstown, OH

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 SCIENCE AND PRACTICE
Safety of medication overrides

Domini Hood, PharmD, Medication Safety Officer, Department of Pharmacy, Sheetal Patel-House, PharmD, MS, System Clinical Manager, Controlled Sub-
University of California Davis Medical Center, Sacramento, CA stances Assessment Program, Pharmacy Services, UNC Health, Chapel Hill, NC

Jennifer Mai, PharmD, BCPS, BCCCP, Inpatient & Infusion Pharmacy Manager, Michelle Then, PharmD, MBA, Pharmacy Manager - Medication Safety, Quality
Department of Pharmacy, University of California San Diego Medical Center, San & Compliance, Department of Pharmacy, Denver Health Medical Center, Denver,
Diego, CA CO

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