Implementation of Institute for Safe Medication Practices (ISMP) Initiatives to Reduce Medication Overrides in the Surgical Intensive Care Unit at Veterans Affairs Academic Medical Center (I-REMO Study)

Background: The automated dispensing cabinets (ADCs) now allow for more rapid access to medications for both providers and pharmacists. However, automation may generate its own challenges with patient care. Medication overrides from ADCs circumvent pharmacist verification and creates an opportunity for medication errors. Methods: A 60-week quasi-experimental study has been conducted at large Veterans Affairs (VA) academic medical center from January 1, 2019 to February 29, 2020 to assess the efficacy of the ISMP-endorsed interventions in reducing medication overrides. Three interventions were implemented for this study: 1:1 nursing education, medication override list, and ADC medication override privilege modification. The interrupted-time series with multiple regression analysis was conducted to assess the efficacy of each intervention. The primary endpoint was the rate of medication overrides (primarily controlled substances and antibiotics) from the unit ADC at each intervention time periods. The secondary endpoints included medication override rates for controlled substances and fentanyl intravenous piggyback (IVPB), the most common overridden item, at each study intervention time periods. The other secondary endpoint was the comprehensive medication override rates for all medications in the unit ADC after November 1, 2019.
Results: Total of 1,783 medication overrides from January 1, 2019 to February 29, 2020 were included in the final analysis from 616 patients. The interrupted time series with multiple logistic regression showed that the 1:1 nursing education significantly reduced the medication overrides (t = -6.10 [95% CI: -15.34 to -7.75]; P < 0.0001) and the decreased trend was maintained afterwards. No significance was found from the medication override list (t = -0.91 [95% CI: -5.17 to 1.94]; P=0.366) and the nursing ADC access privilege restriction (t = -0.82 [95% CI: -4.75 to 1.98; P=0.414]). Secondary endpoints have seen similar results. The 1:1 nursing education significantly reduced controlled substance (t = -6.34 [95% CI: -17.79 to -9.25]; P < 0.0001) and fentanyl IVPB override rates (t = -3.08 [95% CI: -43.69 to -9.28]; P = 0.003). The medication override list did not statistically reduce the controlled substances and fentanyl IVPB; whereas, ADC medication override privilege modification made a significant impact on fentanyl IVPB (t = -2.47 [95% CI: -34.08 to -3.56]; P=0.017). All medication overrides after November 1, 2019 have also significantly decreased monthly medication override rate from 7.63% to 2.90%. Conclusion: An interdisciplinary approach to ISMP-endorsed interventions significantly reduced the overall medication overrides rates in Veterans Affairs intensive care unit.