PSA Advisories

Medication Errors Involving Overrides of Healthcare Technology

Users can bypass many of the safety features incorporated in medication-use technologies that provide warnings about possible unsafe conditions or errors. Analysts reviewed medication error event reports that indicated the use of overrides submitted from January 2013 through December 2014 to the Pennsylvania Patient Safety Reporting System. Of the 583 event reports related to the use of overrides, the most commonly mentioned technology was automated dispensing cabinets (77.0%, n = 449), followed by computerized prescriber order entry (8.2%, n = 48) and bar-code medication administration devices (7.5%, n = 44).The most common classes of medications cited were antibiotics (12.0%, n = 70), opioids, (12.0%, n = 70), and anticoagulants (7.4%, n = 43); and 26.4% (n = 154) of the reports involved at least one high-alert medication. Organizations may consider developing criteria for alerts that focus on real chances of patient harm while preventing alert fatigue, minimizing the need for or use of overrides. (Pa Patient Saf Advis 2015 Dec;12[4]:141-8.)

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