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Autoverification Implementation Toolkit

Autoverification improves the medication management process by eliminating the need for pharmacist medication order verification and facilitating medication administration.

The professional actions of pharmacists to ensure the safe and effective use of medications should be documented in the electronic health record (EHR). These guidelines describe the autoverification functionality, available in EHR’s, which reduces turnaround time for order entry and allows the pharmacist to spend more time on additional clinical services.

Health system electronic health records have improved over the past 30 years incorporating all facets of patient care, documentation and safety.  With the enhanced complexity of healthcare, facilitating electronically transcribed medication orders will be critical to improving patient care and increasing patient safety. 

Autoverification occurs when a medication is entered and released, bypassing the pharmacist verification step, and is automatically verified in the EHR.  In a recent survey, 62.2% of hospitals use autoverification functionality in their computerized provider order entry (CPOE) system.  The use of autoverification has increased significantly since 2016.

Autoverification improves the medication management process by eliminating the need for pharmacist medication order verification and facilitating medication administration. Autoverification algorithms can incorporate critical values, patient history and clinical decision support tools pursuant to medication prescribing.  Initiation of autoverification may result in more effective use of pharmacy personnel and improve medication management quality and efficiency.  In autoverification, medication orders are analyzed by computer software parameters, and if the orders fall within the parameters, the medication order is autoverified.  Results that fall outside of the defined parameters are reviewed by a pharmacist prior to medication administration. 

In a survey of the 62.2% of hospitals that use autoverification, the most common medication order attributes that exclude an order from autoverification include pediatric orders, orders associated with allergy, drug-drug interaction or drug-food interaction, ISMP high-alert medications, and verbal orders.  The primary reasons for not implementing autoverification of provider orders are patient safety concerns, requirements by law, and EHR limitations.  More targeted autoverification is being used for selected medications instead of a broad application of this process.  With the increasing use of autoverification by healthcare systems in the setting of continued concerns for patient safety, the ASHP Section of Pharmacy Informatics and the ASHP Section of Inpatient Care Practitioners Section Advisory Group on Medication Safety collaborated on a joint task force to develop a toolkit for the implementation of autoverification.

Autoverification for Patient Safety

  1. Review federal and state regulations for requirements for verification of medication orders.
    Resource: Medication Management Standard Reference

  2. Review current literature related to autoverification.
    Resource: Literature Reference List

  3. Define scope for autoverification. Consider advantages/disadvantages of autoverification for each defined scope. Work with informatics team to assess electronic health record capabilities.
    Resource: Clinical Considerations Summary

  4. Engage appropriate stakeholders, including, but not limited to, the following:
    a. Senior leadership (e.g. Chief Pharmacy Officer, Chief Medical Information Officer, Chief Medical Officer, Chief Nursing Officer) as appropriate
    b. Risk management
    c. Regulatory affairs
    d. Pharmacy leadership (clinical and operational)
    e. Quality/patient safety
    f. Medication safety
    g. Clinical informatics
    h. Relevant clinical leadership based upon scope of implementation

  5. Draft policy changes to support autoverification within the organization.
    a. Medication-use policies
    b. Downtime policies

  6. Seek appropriate committee approval for policy changes.
    a. Pharmacy and Therapeutics
    b. Relevant clinical leadership/medical staff committees

  7. Evaluate implementation approach (i.e. pilot versus full scale).

  8. Develop process for continued assessment and optimization/new requests for autoverification. Monitoring may include, but is not limited to:
    a. Patient safety events
    b. Technical event
    c. Retrospective analysis of auto-verified orders
    d. autoverification utilization
    Consider utilizing an FMEA approach for determining autoverification status should a request or a safety event arise, with evaluation of the potential likelihood and severity of medication errors.

  9. Develop education plan for all appropriate stakeholders.
    a. Initial roll-out education
    b. Ongoing educational needs

  10. Incorporate autoverification as a consideration into existing processes for new formulary additions or new clinical services.

Download this checklist [PDF]

The ASHP SICP Medication Safety/SOPIT Clinical Decision Support and Analytics Autoverification Task Force evaluated the functionality of two major electronic health records.  The following items should be discussed with a multidisciplinary stakeholder group for consideration of auto-verification in your organization.  Consult with your informatics team to determine your system’s available functionality.

1. Determine inclusion criteria for auto-verification where autoverification would be appropriate for most orders.  Any combination of these inclusion criteria may be considered.
Note: Specific clinical situations may be considered for exclusion from auto-verification based upon discussion in Section 2.

Are there certain patient care areas in which autoverified orders would be acceptable?
Examples: Emergency department, perioperative areas, ambulatory locations, radiology

Are there certain types of orders in which autoverification could be considered?
Examples: Modification or discontinue orders

Are there certain user roles for whom autoverification could be considered?
Examples: Certain provider positions, pharmacist-entered orders

Are there certain orders/order sets in which autoverification would be appropriate if orders are entered exactly as built?
Examples: Emergency/rescue medications, protocol-based order sets, procedural order sets

Are there any clinical situations in which a delay in medication therapy could potentially result in harm to the patient?
Examples: Override medications

2. Discuss the following points regarding which clinical situations may apply or be of concern for auto-verification.

Are there certain types of orders in which autoverification could be a concern?
Examples: Verbal orders, TPN orders, non-formulary orders

Are there certain patient populations for whom autoverification may be a concern?
Examples: High risk patient populations as defined by the organization (pediatrics, oncology, geriatrics, by diagnosis, etc.)

Are there certain medication classes for which autoverification may be a concern?
- High alert medications (anticoagulants)
- Controlled substances
- Medications for which there is a clinical service (antimicrobials in the setting of prospective antimicrobial stewardship)

Are there certain medications with dosing considerations for which autoverification may be a concern?
Examples: Weight-based medications (i.e. vancomycin), weight-based dosing infusion orders, renally dose adjusted medications

Are there certain medications for which auto-verification could be a concern based upon distribution model?
Examples: Automated dispensing cabinet configuration (i.e. profiled/non-profiled), requires manipulation/compounding

Are there certain orders for which auto-verification could be a concern if the order triggers clinical decision support alerts?
Examples: Drug-allergy alert, drug-drug interaction alert, drug dosing alert

Download Checklist [PDF]

Automated dispensing cabinets settings and medication dispensing processes should be evaluated in accordance with federal and state regulations.  These may include requirements established by entities such as the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), DNV, State Board of Pharmacy (BOP), Department of Public Health, or other applicable regulatory bodies.  Specific requirements may vary. 

There currently is not specific language regarding auto-verification in the Medication Management Standards for Hospital Accreditation.

A summary of select Medication Management Standards for Hospital Accreditation that pertain to pharmacist order review and medication dispensing are listed below. 

Medication Management (MM)

Label MM.05.01.01

Standard A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital

Element of Performance

1. Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation (including sudden changes in a patient’s clinical status), in accordance with law and regulation.

Note 1: The Joint Commission permits emergency departments to broadly apply two exceptions in regard to Standard MM.05.01.01, EP 1. These exceptions are intended to minimize treatment delays and patient backup. The first exception allows medications ordered by a licensed independent practitioner to be administered by staff who are permitted to do so by virtue of education, training, and organization policy (such as a registered nurse) and in accordance with law and regulation. A licensed independent practitioner is not required to remain at the bedside when the medication is administered. However, a licensed independent practitioner must be available to provide immediate intervention should a patient experience an adverse drug event. The second exception allows medications to be administered in urgent situations when a delay in doing so would harm the patient.

Note 2: A hospital’s radiology service (including hospital-associated ambulatory radiology) will be expected to define, through protocol or policy, the role of the licensed independent practitioner in the direct supervision of a patient during and after IV contrast media is administered including the licensed independent practitioner’s timely intervention in the event of a patient emergency.
2. When an on-site pharmacy is not open 24 hours a day, 7 days a week, the following occurs:
- A healthcare professional determined to be qualified by the hospital reviews the medication order in the pharmacist’s absence
- A pharmacist conducts a retrospective review of all medication orders during this period as soon as a pharmacist is available or the pharmacy opens
4. All medication orders are reviewed for the following:
- Patient allergies or potential sensitivities
- Existing or potential interactions between the medication ordered and food and medications the patient is currently taking
- The appropriateness of the medication, dose, frequency, and route of administration
- Current or potential impact as indicated by laboratory values
- Therapeutic duplication
- Other contraindications
11. After the medication order has been reviewed, all concerns, issues, or questions are clarified with the individual prescriber before dispensing

Standard Label | MM.05.01.11

Standard The hospital safely dispenses medications

1. The hospital dispenses quantities of medications that are consistent with patient needs.

Note: This element of performance is also applicable to sample medications.
2. The hospital dispenses medications and maintains records in accordance with law and regulation, licensure, and professional standards of practice.

Note 1: Dispensing practices and recordkeeping include antidiversion strategies.

Note 2: This element of performance is also applicable to sample medications
3. The hospital dispenses medications within time frames it defines to meet patient needs.
4. Medications are dispensed in the most ready-to-administer forms commercially available and, if feasible, in unit doses that have been repackaged by the pharmacy or licensed repackager.

Standard Label | MM.05.01.13

Standard The hospital safely obtains medications when the pharmacy is closed

1. The hospital follows a process for providing medications to meet patient needs when the pharmacy is closed.
2. When non-pharmacist health care professionals are allowed by law or regulation to obtain medications after the pharmacy is closed, the following occurs:
- Medications available are limited to those approved by the hospital
- The hospital stores and secures the medications approved for use outside of the pharmacy
- Only trained, designated prescribers and nurses are permitted access to approved medications
- Quality control procedures (such as an independent second check by another individual or a secondary verification built into the system such as bar coding) are in place to prevent medication retrieval errors
- The hospital arranges for a qualified pharmacist to be available either on-call or at another location (for example, at another organization that has 24-hour pharmacy service) to answer questions or provide medications beyond those accessible to non-pharmacy staff

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