Background Automated dispensing cabinet (ADC) medication overrides contribute to increased risks of drug diversion, medication errors, and waste. Pediatric institutions face unique barriers in reducing medication overrides and managing ADC inventory due to developmental- and weight-based dosing needs and a lack of commercially available pediatric dosage formulations.

Objectives A multidisciplinary process improvement team was created to evaluate and reduce inappropriate medication overrides. An initial goal was set for ongoing quarterly 5% reductions in override rate per 1,000 ADC issue transactions.

Methods Lean Six Sigma process improvement methodology was applied to evaluate inappropriate medication overrides and plan a series of improvement initiatives targeting identified root causes. Project scope included all inpatient and outpatient ADCs with the exception of intraoperative care areas.

Results The team identified four root cause categories contributing to inappropriate overrides including data integrity and transparency, organizational culture, equipment and technology issues, and suboptimal operational workflows. A series of unit-specific and system-wide pilots were implemented to address each cause with interventions ranging from educational campaigns to forcing functions. Override rates decreased from a quarterly average of 62.6 in Q4 2020 to 24.8 in Q1 2023 (60% reduction from baseline, p<0.001) (figure 1).

Conclusions By applying Lean Six Sigma methodology, a multidisciplinary process improvement team successfully identified and mitigated several root causes of inappropriate medication overrides. Despite challenges unique to pediatric medication needs, the organization was able to achieve a significant and sustained reduction in the overall medication override rate.

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Abstract 20 Figure 1

Medication override rate (P-chart, with shifting means following 8 or more data points below prior mean)