Medication errors are common in U.S. hospitals and can be deadly; 7,000 to 9,000 Americans die yearly from medication errors.1 The frequent nursing practice of overriding safety warnings in technologies such as smart pumps (see Drug Watch, June) and automated dispensing cabinets increases the risk of a medication error.
Most automated dispensing cabinet systems today interface with the electronic health record, and a pharmacist's verification of a medication is needed prior to the drug's removal. While overriding safety alerts and controls is permitted by software in automated dispensing cabinets, this feature is meant to be used in a true emergency when any delay in treatment could harm a patient.2 Too frequently, the override feature is used in nonemergency situations and may be considered a routine option by some nurses instead of a risky exception. The use of overrides contributes to medication errors so frequently that it is listed as number three on the list of the top 10 health technology hazards for 2023 by the ECRI Institute (go to http://www.ecri.org/top-10-health-technology-hazards-2023-executive-brief).
In 2022, a nurse in Tennessee was found guilty of criminal negligence in the death of a patient after she overrode the controls in an automated dispensing cabinet, searched for the first two letters of the intended drug's name (Ve), and accidentally dispensed vecuronium (a smooth muscle relaxant used as an adjunct in general anesthesia) instead of Versed (the trade name for midazolam, which is a benzodiazepine used for relaxation). She administered the vecuronium to the patient, who subsequently developed muscular paralysis and respiratory arrest and died. During the trial, the nurse admitted both to being distracted and that the situation was not an emergency requiring an override of the safety controls. She was found guilty of criminal charges and also lost her nursing license.3
Nurses need to recognize the risk that overriding programmed controls, such as in automatic dispensing cabinets, poses to patient safety and to avoid overrides except in emergencies. When there is such an emergency, a nurse should consider it a high-risk event and have a second nurse check the drug being dispensed to confirm that it's the right drug.
Nurses should participate on safety committees and support efforts to add enhancements to prevent accidental delivery of the wrong drug. One such enhancement would be to change the software in automated dispensing cabinets to require at least five letters of a drug's name in the search field before the drug is dispensed. Pharmacy safety committees should also regularly review overrides to determine how frequently they are occurring and why they were necessary.
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