Evidence
The published literature that motivates Safer-Med — each figure with its setting, sample size and date, because a chief pharmacy officer will check and should.
ISMP's 2019 guidelines for the safe use of automated dispensing cabinets set a target of no more than 5% of withdrawals on override, and call for proactive override auditing. A 2024 quality-improvement project in a perianesthesia care unit reported a monthly override rate falling from 17% to 8% and then to 4%, only after sustained intervention. Read as: one unit, one institution, a QI report rather than a trial.
A retrospective audit published by AHRQ examined 59 override transactions at a psychiatric facility and judged about 15% — 9 of 59 — inappropriate: no documented order, wrong drug, dose or route, or a disregarded allergy warning. Read as: a small, single-site, 2008 sample. It is indicative, not a population estimate, and we will not present it as one.
Because an override obtains a medication before any pharmacist reviews the order, the gravest failure is a wrong-drug selection. In the widely reported 2017 case at Vanderbilt University Medical Center, a nurse using an automated-dispensing-cabinet override withdrew the paralytic vecuronium instead of the sedative Versed (midazolam); the patient, Charlene Murphey, died. Read as: a single, widely documented case — illustrative of the risk that bypassing pharmacy review creates, not a population estimate.
Slight and colleagues, in JAMIA in 2018, projected a total annual cost of $871 million to U.S. hospitals to treat preventable adverse drug events resulting from inappropriate medication-related alert overrides — excluding injury and malpractice costs. Read as: a modeled national projection covering medication-related alert overrides generally, not cabinet overrides specifically.
The Joint Commission's R3 Report Issue 19, establishing the National Patient Safety Goal for anticoagulant therapy effective 2019, cites anticoagulant-related adverse drug events contributing over $2.5 billion in annual U.S. hospital costs. The 2019 expansion added explicit expectations around real-time monitoring and dose-appropriate management.
References