IHA case studies

Lean Six Sigma Reduces Risk of Medication Errors Due to Medical Dispense Overrides by 53% in a Critical Access Hospital


Medical dispense overrides allow nurses to dispense medications from the Pyxis machine without pharmacy review in emergency situations. However, increasing the incidence of medication overrides can lead to greater risk of medication errors. For the period between Jan. 1, 2014, and March 31, 2014, a critical access hospital recorded 510 total Pyxis medical dispense overrides, and providers were overriding the machines an average of 5.9 times per day.

The project team set a goal of reducing overrides to fewer than three per day. The team discovered a workload balancing issue was causing bottlenecks in the process. To address this issue, additional trained employees and the pharmacist were made available to help during high-intensity workload times and computerized physician order entry was fully implemented. After the project pilot and implementation, the hospital experienced an average of 2.8 overrides per day, a reduction of 53 percent.

This case study is part of the Illinois Health and Hospital Association's annual Quality Excellence Achievement Awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals and health systems in continually improving and transforming health care in the state. These organizations are improving health by striving to achieve the Triple Aim—improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care—and the Institute of Medicine’s six aims for improvement—safe, effective, patient centered, timely, efficient, and equitable. To learn more, visit https://www.ihaqualityawards.org/javascript-ui/IHAQualityAward/

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