Unsafe doses leave the cabinet on override
On override, a nurse pulls a medication before any pharmacist reviews the order — and a wrong-drug pull can be fatal. A paralytic withdrawn in place of the sedative it sits beside, under time pressure, can kill a patient — and such substitutions have. It is a systems failure, not a nursing failure: the medication travels from cabinet to bedside with nothing re-checking it. ISMP recommends limiting overrides to situations where waiting for pharmacist review could adversely affect the patient, and reviewing their appropriateness — but overrides remain common in practice.
