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Closing the Back Door: Fixing a Workaround Improves Medication Safety

Gerald Maloney, DO, FACEP, FACMT

Gerald Maloney, DO, FACEP, FACMTWhile there is data showing some patient safety advantages to computerized physician order entry (CPOE), such as reduction in errors due to transcription, there have been new errors that have been identified, such as those associated with developing workarounds to complicated ordersets. As boarding hours increased at our facility, the number of patients on IV infusion medications, such as heparin, that were boarding in the ED also increased.

The initial ED orderset for heparin provided for the initial bolus and infusion, but there were no parameters for monitoring and rechecks of the PTT and dose adjustment. As delays of hours to days became common, the need to have an orderset became pressing as review of patient safety concerns showed that many patients were arriving to the floors with their PTT in a supra- or sub-therapeutic range. The adoption of the orderset used for inpatient heparin infusions was adapted to the ED.

One significant issue that came up during the ordering was the patient weight. If the weight was not entered by the nurse when she entered vitals into her flowsheet, then the orders could not be completed. A workaround for the physician to enter the weight was found, and the orderset seemingly would then proceed as usual. A warning bell was designed to show up on the trackboard 5 hours and 30 minutes after the infusion was started to alert the nurse to draw a repeat PTT so the infusion could be adjusted for the 6-hour mark. However, it was quickly discovered that the warning prompt-which had been working well to significantly improve the number of patients maintaining a therapeutic range for their PTT-was not working on some patients. It was determined that the workaround being used by the physicians to enter the patient’s weight was then disabling the features of the orderset designed to prompt monitoring of the PTT and infusion.

Our initial response was education – the physicians (residents and attendings) were explicitly directed not to enter the weight, and the heparin orderset included a nursing order to enter the weight of the patient if not already obtained. Ultimately the ability of the providers to enter the weight into the orderset directly was disabled. The number of orderset problems related to the workaround decreased by 90% after the educational intervention, and ultimately disappeared completely with the end of the workaround.

While this is a single ED intervention, it carries some important medication safety tips. CPOE has generated new potential errors, such as those resulting from workarounds to improve workflow when using a complicated orderset. Such workarounds need to be identified and if causing potential harm to a patient ended through educational and if possible technological interventions.


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