Limit Use of ADC Overrides to Keep Patients Safe

Healthcare workers were outraged last year over the criminalization of a medical error by critical-care nurse RaDonda Vaught, who was found guilty of two felonies, lost her RN license and sentenced to three years of probation for administering the wrong drug to a patient. They were also frightened that they, too, could be arrested if they made a similar mistake.

But patient-safety groups such as ECRI, a Philadelphia-area based nonprofit, have been sounding the alarms about cases such as the one in Oklahoma that involved Ms. Vaught for years. In her case, Ms. Vaught typed in “VE” while using the override function in an automated dispensing cabinet (ADC) in 2017 to get the sedative Versed for 75-year-old patient Charlene Murphey. The medication cabinet instead gave Ms. Vaught access to the powerful paralytic vecuronium, which she administered to the patient and caused her death.

Similar errors continue to happen, which is why the issue made ECRI’s list of Top 10 Health Technology Hazards for 2023, which was released in January. The list states, “Inappropriate use of automated dispensing cabinet overrides can result in medication errors.”

It’s appropriate to heed ECRI’s warning and take the time to read the agency’s suggestions on how to reduce these errors this month, as National Patient Safety Awareness Week is observed from March 12-18. Organizations across the country, including The Joint Commission, Institute for Healthcare Improvement and the Center for Patient Safety use the week as an educational opportunity to help reduce medical errors, which are estimated to cause as many as 400,000 deaths in the U.S. each year. Only heart disease and cancer kill more people.

ECRI notes that overrides should only be used during true emergencies. Overusing the feature is always risky, as it bypasses a thorough review of the medication order before it’s given to the patient.

“Some high-profile medication error events, including fatal incidents, have been associated with the inappropriate use of an ADC’s override feature,” notes ECRI in its report that accompanies the top 10 list. “Concerningly, the Institute for Safe Medication Practices (ISMP) has found that, too often, practitioners view the override process as a routine step, rather than a risky one.”

The report states the override feature should only be used when even a short delay in administering a medication would put a patient at risk. How often overrides are used should be tracked and routinely monitored by facility leadership.

ISMP officials have said that manufacturers of cabinets should implement a change in their products’ software to force healthcare workers to type in the first five letters of a medication before it could be dispensed. Visit www.ismp.org for free resources, including its guidelines for safe use of automated dispensing cabinets, best medication safety practices for hospitals, a discussion of the overuse of ADC overrides, as well as a list of safety enhancements every facility should consider in order to prevent more tragic neuromuscular blocker events. OSM