From the March 24, 2005 issue

Problem: For years, healthcare providers have been struggling with what appears to be a fairly simple issue: How do you hold a single dose or several doses of a medication, be it warfarin, insulin, or any other medication? Oftentimes, an order to hold a medication results in either forgetting to resume it when appropriate, or resuming it too soon. A few examples follow.

An elderly woman had already been hospitalized for several days when the attending physician requested a gastroenterology consult to determine if she was bleeding. He also wrote an order to "Hold Coumadin" with no other parameters. Per protocol, the pharmacy interpreted this order as a discontinuation of COUMADIN (warfarin). The gastroenterologist performed an endoscopy, showing benign results. After the procedure, he rewrote the orders for all previous treatments and active medications using the patient's current 24-hour computer-generated medication administration record (MAR) as a reference. However, since warfarin was no longer an active order, it was not listed on the MAR. Thus, warfarin was not prescribed post-procedure. Six days later, the patient suffered a stroke directly related to inadequate anticoagulation. Similar errors have been reported in outpatient settings. Many physicians have forgotten to restart warfarin, after placing it on hold, once the subsequent INR has fallen within a therapeutic range.

The opposite type of error can happen, too. In one case, a physician wrote an order to hold LOVENOX (enoxaparin) before a patient underwent implantation of a pacemaker, and to resume the medication 48 hours after the procedure. However, the MAR did not instruct the nurse to await the specified timeframe before restarting the drug. Thus, she accidentally gave the patient a dose of Lovenox as soon as he returned to the ICU after the procedure.

Safe Practice Recommendation: If a patient is receiving daily medications such as warfarin in doses that are based on daily lab results, the pharmacy profile and the nursing MAR should reflect this as an ongoing active order listing just the drug, route, and frequency, with clear annotation on the records to make sure that a dose is prescribed each day according to lab values. Each daily prescribed dose should then be documented in the pharmacy profile and the nursing MAR. If a dose must be held due to a high INR value, an order for "No warfarin today" should be received and documented on the MAR and pharmacy profile.

If medication doses are not guided by daily lab values, hold orders are not safe unless the prescriber includes specific instructions indicating when to resume the medication, and the specific instructions are clearly visible on the pharmacy profile and the nursing MAR. For example, an order to hold furosemide for 48 hours should not result in discontinuation of the drug, but clear annotation on the pharmacy profile and the nursing MAR of the conditions for holding and resuming the drug.

Orders to hold a medication without specific instructions on when to resume the medication should not be allowed. Instead, prescribers should simply discontinue the medication. If a hold order is received, a nurse or pharmacist should clarify the order to learn if specific conditions can be added for resuming administration. If not, the drug should be discontinued. Of course, these are the most error-prone orders, as the discontinued medications simply drop off the pharmacy and nursing profile and resumption could easily be forgotten. However, there is still one very powerful way to avoid errors, or to detect them more quickly. The pharmacy computer can often generate a daily summary of prescribed therapy for each patient (prepared during the night) that is placed on the patient's chart for physician review. These summaries should include, in a discrete section, a list of medications discontinued within the past 3 to 5 days. Physicians should be required to review the summaries for accuracy of order interpretation. Thus, any inadvertent discontinuation or continuation of a drug could be captured quickly and adjusted. The summaries would also help physicians when re-prescribing therapy after a procedure (or upon discharge). Electronic drug summaries may be used if available as long as they include discontinued medications and physicians have easy access to them.

While orders to hold a medication until after a procedure clearly include instructions on when to resume administration, these orders should also be disallowed since all medications should be re-prescribed after such a transition in care, and the newly prescribed medications should be reconciled with the previously prescribed medications. (See the Joint Commission 2005 National Patient Safety Goals and the announcement below about an upcoming ISMP teleconference on medication reconciliation in April). If computerized prescriber order entry is available, it may be possible to place pre-procedure orders in a queue and re-prescribe them by releasing each individual drug as appropriate. Applicable post-procedure standardized order sets can also help if they contain prompts to remind prescribers to resume particular medications such as anticoagulants.

In outpatient settings, physicians should establish a method of tracking medications placed on hold, and a tickler system for contacting patients regarding further instructions for resuming the medication. Patients should also be told when to expect a call, and if not received, to contact the physician's office before the end of the day to serve as a reminder.

If you have additional recommendations for handling hold orders that have been successful in your organization, please contact us so we can share them with others.