Hi there,
I am a PGY2 Medication Use Safety and Policy pharmacy resident! I am reaching out in regards to a serious safety event that occurred at our institution involving resuming/reordering of a heparin infusion at a higher rate than intended. In this case, it unfortunately passed through the provider, pharmacist and nurse to fit the perfect Swiss cheese model. We currently are using Epic and have a heparin nursing-driven protocol in place with guidelines for initiation of a heparin infusion versus resuming. What is the best practice and/or what has your institution implemented in Epic for scenarios involving holding and resuming of these orders (procedural holds/suspected bleeding holds/etc)? Appreciate your insight!
Best,
Lena DeVietro, PharmD, BCPS