From the March 24, 2005
: 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
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
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.