Verbal Orders and Medication Overrides: A Dangerous Combination Catherine Mueller, PharmD, CPPS, Paul MacDowell, PharmD, BCPS, and James A. Bourgeois, OD, MD | April 24, 2024

https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination A 26-year-old man presented to the emergency department (ED) with abdominal pain, displaying tachycardia and extreme agitation. Despite negative findings on physical examination and laboratory tests, his aggressive behavior escalated, necessitating physical and chemical restraint for the safety of both himself and ED staff. The ED physician verbally ordered 10 mg of intramuscular haloperidol, but the primary nurse overrode the automated dispensing unit and mistakenly pulled a vial of midazolam 10 mg instead of haloperidol. Flumazenil was subsequently administered to reverse benzodiazepine toxicity, and the patient recovered without further complications. The commentary discusses best practices to promote safe medication administration in the context of verbal orders and medication overrides.