Skip to main content

New ISMP 2020-2021 Targeted Medication Safety Best Practices for Hospitals (Part 2)

July 08, 2020

By Yashar Rafi, PharmD, 2019-2020 ISMP Safe Medication Management Fellow

In the first part of this blog, we looked at the new Best Practice 15 from the 2020-2021 Targeted Medication Safety Best Practices for Hospitals which deals with fentanyl patches and extended-release and long-acting opioid products. In this blog, we look at the new Best Practice 16 which sets out some best practices for using the override feature on automatic dispensing cabinets (ADCs). 

Best Practice 16: ADC “Override” Feature 

a) Limit the variety of medications that can be removed from an ADC using the override function.

b) Require a medication order prior to removing any medication from an ADC, including those removed using the override function.

c) Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.

d) Periodically review for appropriateness the list of medications available using the override function. 

ISMP continues to receive reports of medication errors – including fatalities – involving the use of the override feature on ADCs. The override feature allows healthcare providers to remove a medication from the ADC without having to wait for pharmacy review or approval of the medication order. This lack of pharmacist review opens the door to potential medication errors. In essence, the process is fraught with risk and should only be employed when waiting for pharmacist review would potentially pose a greater risk to the patient than the inherent risk of the override itself.  

It is important to note that a medication order is a prerequisite of the override process. Simply removing medication from an ADC without an order is not an override. As a basic safety measure, an order should always be required before a medication can be removed from the ADC – even in emergent situations that would justify an override.

In addition to requiring an order for all ADC medications, organizations should limit the use of the override feature by establishing and maintaining a list of medications that are appropriate for use via override. This list should be limited to only those medications that would be needed emergently (e.g., antidotes, rescue and reversal agents, life-sustaining drugs, and comfort measure medications such as those used to manage acute pain or intractable nausea and vomiting). One factor that leads to overuse of overrides is the tendency to view the override list as a list of medications that can routinely be removed without pharmacist review. This dangerous practice needs to be proactively discouraged through provider education and training – use of the override feature is appropriate only in an emergency. Retroactive review of overrides should also be performed periodically to ensure that the process is being used only when appropriate.

ISMP is conducting a short survey to get a sense of the baseline level of implementation of these 2 new Best Practices. We would appreciate your participation in this survey regardless of whether you have implemented the Best Practices. The online survey will remain open until July 17, 2020

In addition to the two new Best Practices that we have considered in this series, five of the 2018-2019 Best Practices were revised or archived in 2020. For more information, including a link to a list of Frequently Asked Questions (FAQs) please refer to the full article:

ISMP’s Guidelines for the Safe Use of Automated Dispensing Cabinets provide many more recommendations for the safe use of ADCs:



ISMP. Two New Best Practices in the 2020-2021 Targeted Medication Safety Best Practices for Hospitals. ISMP Acute Care Medication Safety Alert! 2020; 25(4):1-4.

Agree or disagree with an article? Share your professional thoughts on an article you read.

Your Name
8 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Back to Top