CHPPC Module 18, Section 1: Work Queues & Verification Mastery
Part 5: Data Entry & EHR Mastery (New Track)

Module 18: Epic (Willow Inpatient) — Order Entry & Verification

18.1 Work Queues & Verification Mastery: Your Digital Command Center

Transitioning from a linear prescription-based workflow to a dynamic, prioritized queue-based system.

This is the single most significant operational and philosophical shift you will make in your transition to hospital practice. The familiar, linear rhythm of retail—a prescription is dropped off, entered, filled, and checked in sequence—is replaced by a dynamic, constantly shifting digital work queue. The Epic verification queue is the central nervous system of the inpatient pharmacy, the digital equivalent of an air traffic control tower for every medication order in the institution. It is a prioritized, filterable, and collaborative workspace where all medication orders for the entire hospital converge. Mastering its navigation and management is the foundational skill upon which all other Epic-based competencies are built. It is your primary tool for managing workload, triaging priorities, and ensuring timely and safe medication delivery on a massive scale. Welcome to your new command center.

Retail Pharmacist Analogy: The Mental Queue vs. The Digital Queue

In your retail pharmacy, you are the master of a complex “mental queue.” At any given moment, you are simultaneously juggling the waiting prescriptions at the counter, the e-scripts that just arrived, the script on hold from the fax machine, the patient on hold on line 2, and the immunization that just walked in. You use your professional judgment to constantly re-prioritize these tasks in your head. It’s an incredibly demanding cognitive feat that is invisible to everyone else.

Epic’s verification queue is that complex mental model made tangible, visible, and collaborative. Instead of keeping it all in your head, the EHR organizes every single one of those competing demands into a single, shared list. It automatically flags the STAT orders, tells you how long each order has been waiting, and allows you and your pharmacist colleagues to work from the same prioritized list in real-time. Your inherent skill at multitasking and prioritization is not being replaced; it’s being supercharged and amplified by a powerful organizational tool. You are trading an invisible, stressful mental load for a visible, manageable, and team-oriented digital one.

18.1.1 The Anatomy of the Verification Queue: A Deep Dive into the Data

The main verification queue in Epic is often referred to by its activity name, “VCN” (Verification for a Clinical Navigator), or simply the “InBasket.” While the specific columns and layout can be customized by each hospital, the core data elements are universal. To an untrained eye, it’s a wall of text. To a skilled hospital pharmacist, it’s a rich, data-dense dashboard that tells a dozen stories at once. Let’s deconstruct each key element.

18.1.1.1 Deep Dive: Priority Column

This is the most important column for immediate triage. It’s not just a label; it’s a direct command about where your attention must go first. Hospitals typically use a color-coded system to make priorities instantly recognizable.

  • STAT (Red): From the Latin “statim” (immediately). This is the highest priority. These orders are for life-threatening situations where a delay of even a few minutes can impact patient outcomes. Your personal and departmental goal is to verify STAT orders in under 5-15 minutes.
    • Example Scenario: A patient arrives in the ED with septic shock, and the provider orders STAT norepinephrine, STAT vancomycin, and STAT cefepime. These orders will appear at the very top of your queue, highlighted in bright red, bypassing all other work.
  • ASAP (Yellow): “As Soon As Possible.” This is a step down from STAT but still indicates urgency. These are for conditions that require prompt treatment but are not immediately life-threatening. The expectation is to verify these after all STATs are cleared, typically within 30-60 minutes.
    • Example Scenario: A patient with community-acquired pneumonia needs their first dose of ceftriaxone, or a post-operative patient needs their first dose of IV hydromorphone for pain.
  • Routine (White/No Color): The bulk of your queue. These are for scheduled maintenance medications or non-urgent new orders. While less urgent, they must be managed efficiently to ensure the first dose is given at the correct scheduled time.
    • Example Scenario: A daily lisinopril order for a stable patient, a new bedtime trazodone order, or a daily multivitamin.

18.1.1.2 Deep Dive: Patient Location Column

This column provides crucial clinical context. A pharmacist doesn’t just verify drugs; they verify drugs *for a patient in a specific clinical setting*. The same medication order can have vastly different implications based on the patient’s location.

Reading the Map: How Location Shapes Your Verification

A skilled pharmacist uses the Location column to instantly adjust their clinical mindset:

  • ED (Emergency Department): Mindset is SPEED & STABILITY. Patients are often undiagnosed. Focus on rapid medication delivery for acute conditions, admission medication reconciliation, and identifying potential toxicities or overdoses. An antibiotic order here is likely a first dose for a new, serious infection.
  • ICU (Intensive Care Unit): Mindset is PRECISION & VIGILANCE. This is the land of high-alert, titratable drips. Every order (pressors, sedatives, anticoagulants) requires meticulous review of calculations, concentrations, and monitoring parameters. Patients are unstable, and labs can change hourly.
  • Med/Surg Floor (e.g., “6 North”): Mindset is ROUTINE & TRANSITION. Focus on maintenance medications, pain management, IV-to-PO conversions, and preparing for discharge. An antibiotic order here may be a continuation of therapy started in the ED or ICU.
  • ONC (Oncology/Infusion Suite): Mindset is PROTOCOL & SAFETY. Verification is rigidly guided by complex, multi-drug chemotherapy regimens. Focus is on cycle/day confirmation, pre-medication timing, and absolute adherence to lab safety parameters (e.g., ANC, platelets).
  • PEDS/NICU (Pediatrics/Neonatal ICU): Mindset is WEIGHT-BASED & FORMULATION. Every single dose is calculated based on a precise weight in kilograms. Concentration and diluent choices are critical. There is zero room for error.

18.1.1.3 Deep Dive: Other Critical Columns

Column Name What It Tells You Advanced Application & Clinical Nuance
Time in Queue A running clock showing how long the order has been waiting for verification. This is your service-level metric. A “Routine” order sitting for 2 hours is now a problem. It might mean a patient misses a scheduled dose. You use this to self-manage and to identify when the team is falling behind and needs help.
Medication Name The drug that has been ordered. Beyond simple identification, you scan this column for patterns. Seeing multiple anticoagulants for the same patient? Seeing an unfamiliar non-formulary drug? This column allows for quick “gestalt” pattern recognition before you even open the chart.
Order Status The current state of the order (e.g., New Order, Clarification Needed, Pending). This is a workflow management tool. A queue full of “Clarification Needed” statuses tells you that you are heavily reliant on provider responses. It’s a signal to follow up on your pending messages or to analyze if your communication could be clearer to get faster responses.
Pharmacist The pharmacist who is currently working on or has “claimed” the order. In a remote or decentralized model, this is your primary tool for team awareness. It lets you see who is handling the most complex orders and might need assistance, and it prevents the dangerous situation of two pharmacists working on the same high-risk order simultaneously without realizing it.

18.1.2 The Verification Workspace: Your Clinical Cockpit

When you select an order, Epic takes you to the Verification Workspace. This is not just a screen; it’s an integrated environment designed to give you all the necessary data to make a clinical decision. It typically features the order itself, the patient’s full medication profile, lab results, provider notes, and communication tools, all in one place. The core workflow is a systematic loop: Review, Decide, Act, Document.

  1. Claim & Review (The Chart Dive): Your first action is a rapid but thorough chart review. Before you even analyze the dose of the new order, you must understand its context. This is the “situational awareness” phase.
    • Glance at the Banner: Check the patient’s name, weight, age, allergies, and code status.
    • Scan the Problem List: What are the patient’s chronic conditions? (e.g., CKD, CHF, Cirrhosis).
    • Check Recent Labs: What is the trend of the SCr? The K+? The LFTs? The platelets?
    • Read the Latest Progress Note: What is the clinical team’s plan for the day? This provides the “why” behind the order.
  2. Decide (The Clinical Judgment): Now, with context, you analyze the order itself using all the principles from Module 17. Is it the right drug, dose, route, and frequency for this specific patient, with their specific organ function, on this specific day? Does it interact with any other medications on the MAR?
  3. Act (The Intervention or Approval):
    • If Perfect: You click the “Verify” or “Accept” button. This is your digital signature, your professional stamp of approval. It releases the order into the hospital’s medication ecosystem.
    • If Flawed: You do NOT verify. You initiate an intervention. This could be sending an In Basket clarification message, discontinuing the incorrect order and entering a new one per protocol, or calling the provider for a direct conversation. You then change the order status to “Clarification Needed,” which removes it from the active queue and places it in a pending state.
  4. Document & Move On: Every action must be documented with a concise, professional note. Once you’ve acted, you close the workspace and immediately select the next priority order from the queue. This entire loop can take anywhere from 30 seconds for a simple order to 30 minutes for a complex chemotherapy plan.

18.1.3 Masterclass: Deconstructing Complex Orders in the Queue

Not all queue items are single medications. Epic uses sophisticated order sets, protocols, and plans that require a higher level of verification scrutiny. Your job is to verify the entire strategy, not just the individual components.

18.1.3.1 Linking Related Orders: The Therapeutic Package

A single therapeutic action often requires multiple related orders that must be verified together as a “package.” Epic’s “linking” function is a critical safety feature that groups these items. When you see a linked order, you are legally and professionally responsible for verifying all of its components as a single, functional unit.

Failure to Verify the Full Linked Set is a Critical Error

Imagine a provider orders a STAT dose of IV acyclovir for suspected herpes encephalitis. The acyclovir requires significant pre- and post-hydration with IV fluids to prevent nephrotoxicity. A correctly built order set will link the acyclovir order to two orders for IV saline boluses. If you verify the acyclovir but ignore or miss the linked fluid orders, you are creating a high-risk situation where the nurse could administer the drug without the necessary renal protection. You didn’t just verify a drug; you broke a safety protocol. Always look for, and verify, the entire linked therapeutic package.

18.1.3.2 Protocols and Order Sets: Verifying the Logic

These are pre-built collections of orders designed to standardize care for specific conditions (e.g., Sepsis Protocol, Heparin Nomogram). When a provider initiates a protocol, it may generate a dozen or more orders that land in your queue simultaneously. Your job is not just to verify each individual order, but to confirm that the patient is an appropriate candidate for the protocol’s logic.

Case Study: Deconstructing a Heparin Protocol Verification

A provider orders the “Weight-Based Heparin Protocol” for a patient with a new DVT. Your queue populates with several linked orders. Here is your thought process:

  1. Is the Protocol Appropriate? First, you check the patient’s chart. Is there any contraindication? History of HIT? Active, severe bleeding? Recent neurosurgery? If so, the entire protocol is wrong.
  2. Verify Patient Weight: The entire protocol is weight-based. You must confirm an accurate, recent weight is documented in Epic. An incorrect weight will make every single dose and rate calculation incorrect.
  3. Verify the Bolus Dose: The first order is for an IV bolus (e.g., 80 units/kg). You perform the manual calculation to double-check Epic’s math.
  4. Verify the Initial Infusion Rate: The second order is for the initial continuous infusion rate (e.g., 18 units/kg/hr). You again verify the math.
  5. Verify the Lab Orders: The protocol includes linked orders for a baseline PTT/Anti-Xa and a follow-up lab 6 hours after the first rate change. Are these present? Without them, the infusion cannot be safely monitored.
  6. Verify the Nursing Orders: The protocol also contains the titration nomogram itself—the “if-then” logic for the nurse (e.g., “If PTT is 50-70, increase rate by 1 unit/kg/hr”). You read through this to ensure it’s the correct, institution-approved nomogram.

Only after verifying all these components do you “Accept” the entire package. You have verified a dynamic therapeutic algorithm, not just a drug.

18.1.3.3 Therapy Plans (Oncology): The Ultimate Verification Challenge

Chemotherapy regimens are the most complex order sets you will encounter. A “Therapy Plan” in Epic contains the entire multi-day or multi-week treatment regimen, acting as a blueprint and calendar for the patient’s cancer treatment.

Verifying a Calendar, Not Just a Dose

When you verify a chemotherapy plan, your responsibilities expand significantly:

  • Confirming the Correct Cycle and Day: Your first and most critical check. Is this truly Cycle 2, Day 1 of the R-CHOP regimen? Verifying the wrong day can lead to a catastrophic overdose or underdose. You cross-reference the plan with the patient’s treatment history and provider notes.
  • Verifying All Pre-medications: You ensure that all required antiemetics (e.g., ondansetron, dexamethasone) and hypersensitivity pre-medications (e.g., diphenhydramine, famotidine) are ordered and scheduled to be administered at the correct time intervals before the chemotherapy agent.
  • Verifying Hydration & Supportive Care: You confirm that any required pre- or post-hydration fluids are ordered. You also verify supportive care agents, like growth factors (e.g., filgrastim), are scheduled for the correct days *after* the chemotherapy is complete.
  • The Final Safety Check: Before releasing any chemotherapy, you perform a final review of the patient’s most recent labs (ANC, platelets, creatinine, bilirubin) and compare them to the safety parameters built into the therapy plan. If the ANC is too low, you do not verify. You place the order on hold and immediately contact the oncologist.

Verifying a therapy plan is a holistic, time-sensitive review of a long-term treatment strategy, where your clinical judgment is the final and most important safety net.