Pyxis Override Audit

Audit of automated dispensing cabinet overrides to review override frequency, reasons, and pharmacy follow-up actions.

Audit Identification

• Audit period documented
  Record the start and end dates for the override audit period.
• Location, unit, or cabinet identified
  Document the Pyxis/ADC location, unit, or cabinet reviewed.
• Reviewer name and role documented
  Enter the name and role/title of the auditor or reviewer.
• Review scope defined
  Select the scope of the audit review.
• Reference policy or SOP documented
  List the policy, SOP, or medication management standard used for the review.

Override Frequency and Pattern Review

• Override rate reviewed against expected use
  Enter the override count or rate for the audit period and compare it to expected operational use.
• High-frequency override pattern identified
  Determine whether the unit, shift, medication, or user shows repeated override activity that warrants follow-up.
• Overrides concentrated during specific shift or time window
  Assess whether overrides cluster during nights, weekends, admissions surges, or other predictable periods.
• Repeat override users or prescribers identified
  Identify whether the same staff members, prescribers, or care areas are associated with repeated overrides.
• Trend compared with prior audit period
  Select the direction of change compared with the prior review period.

Override Reason and Clinical Justification

• Reason for override documented in dispensing record
  Confirm that a reason for each reviewed override is documented in the ADC or associated medication record.
• Reason aligns with urgent or time-sensitive clinical need
  Assess whether the override was justified by urgent care needs, emergent treatment, or another approved exception.
• Non-urgent or convenience-based override identified
  Identify overrides that appear to bypass standard verification without a documented urgent clinical need.
• Override reason category
  Select all applicable reason categories for the reviewed overrides.
• High-alert medication or controlled substance involved
  Indicate whether any reviewed override involved a high-alert medication, controlled substance, or other restricted item.

Pharmacy Follow-Up and Documentation

• Pharmacy review completed for reviewed overrides
  Confirm that pharmacy reviewed the override events within the expected follow-up timeframe.
• Medication order entered or verified after override
  Confirm that a corresponding medication order was entered, verified, or reconciled after the override as applicable.
• Discrepancies or undocumented doses investigated
  Determine whether any mismatches between override removal and order verification were investigated and resolved.
• Follow-up action documented
  Select all follow-up actions taken by pharmacy, leadership, or the unit.
• Corrective action owner and due date assigned
  Document the responsible owner and target completion date for any corrective action.

Risk, Compliance, and Escalation

• Potential patient safety risk identified
  Assess whether the override pattern suggests a patient safety risk, delay in care, or medication-use process failure.
• Repeat non-conformance requires escalation
  Determine whether repeated override issues require escalation to pharmacy leadership, nursing leadership, or the medication safety committee.
• Controlled substance or diversion concern escalated
  Indicate whether any override pattern raised concern for diversion, unauthorized access, or controlled substance handling issues.
• Overall audit conclusion
  Select the overall result of the audit review.