CHPPC Section 18.5: Common Epic Pitfalls
Part 5: Data Entry & EHR Mastery (New Track)

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

18.5 Common Epic Pitfalls: A Pharmacist’s Guide to Proactive Error Prevention

Developing the expert-level pattern recognition needed to spot and intercept the most common and highest-risk errors in the Epic workflow.

You have now toured the digital infrastructure of the inpatient pharmacy, from the grand strategy of the work queues to the intricate mechanics of the Order Composer and the vigilant oversight of BestPractice Advisories. The final stage of your mastery is to develop a form of “digital intuition”—an expert-level ability to instantly recognize the subtle signs of a brewing medication error that are specific to the Epic environment. Errors in a complex system are rarely born from a single, catastrophic mistake. Instead, they are often the result of small, seemingly minor deviations from best practice that cascade into significant patient harm. This masterclass is a deep dive into these common failure modes. We will move beyond the obvious alerts and into the grey areas of the workflow where your proactive vigilance is the most critical safety net. You will learn to see not just what is *in* the order, but what is *missing* from it, transforming you from a reactive verifier into a true guardian of the medication use process.

Retail Pharmacist Analogy: The “Problem” Prescription Bin vs. The Expert’s Sixth Sense

In your retail pharmacy, you have a physical “problem bin” for prescriptions with obvious issues—no sig, illegible handwriting, missing DEA number. These are easy to spot and set aside. But your true expertise lies in your sixth sense for the prescriptions that *look* perfect but *feel* wrong. It’s the oxycodone script from a dentist for a patient you know has a history of opioid misuse. It’s the high-dose lisinopril for an elderly patient who just picked up a different ACE inhibitor last week. It’s the “too-perfect” handwritten script for a controlled substance. You don’t need a computer to tell you these require a deeper look; your pattern recognition, honed over thousands of interactions, flags them for you.

This section is designed to build that same sixth sense for the digital world of Epic. We will teach you to recognize the digital equivalents of those “looks right, feels wrong” scenarios. You’ll learn to spot the order for a weight-based drug on a patient who mysteriously has no documented weight, the custom-compounded IV drip that bypasses all the smart pump safety libraries, and the missing IV flush that will cause a critical dose of potassium to be left in the tubing. These are the errors that a novice might miss, but that you, as a CHPPC-certified professional, will learn to intercept with instinctual precision.

18.5.1 Pitfall 1: The Weightless Patient & The Danger of Default Dosing

This is arguably the single most fundamental and dangerous data omission in the EHR. A patient’s weight is not just a demographic detail; it is a foundational clinical parameter upon which hundreds of critical dosing decisions are made. An order for a weight-based medication entered on a patient without a documented weight is a ticking time bomb.

18.5.1.1 Why This Happens and Why It’s So Dangerous

In the chaos of an emergency department admission, obtaining an accurate weight, especially for a non-ambulatory patient, can be challenging. A provider, focused on stabilizing the patient, might enter an order and bypass the weight field, intending for the nurse to document it later. However, many EHR builds will use a “default” or “placeholder” weight if one isn’t available, leading to potentially catastrophic miscalculations.

The Pediatric Nightmare Scenario

Consider a 15 kg pediatric patient admitted to the ED. The provider orders IV vancomycin. If the patient has no weight documented, some systems might default to a standard adult weight (e.g., 70 kg) for the dose calculation helper. The provider, working quickly, might accept the calculated dose. If you, as the pharmacist, do not recognize that the patient is a child and that the weight is a default, you could inadvertently verify a 1-gram dose of vancomycin for a toddler who should be receiving 225 mg. This is a “never event” that has led to real-world patient harm. The absence of a documented, plausible weight for any patient—especially a child—is a hard stop.

18.5.1.2 Your Proactive Detection and Intervention Workflow

  1. Develop “Weight-Aware” Vision: Train yourself to make the patient weight field in the banner one of the first things you look at for *every* order. Does it exist? Does it seem plausible for the patient’s age and gender? A 70 kg weight for an 8-year-old is as dangerous as a missing weight.
  2. Recognize High-Risk Drugs: Your internal alarm should ring loudest for drugs that are almost always weight-based.
    • Anticoagulants: Heparin drips, enoxaparin.
    • Many Antibiotics: Vancomycin, aminoglycosides, acyclovir.
    • Vasoactive Drips: Dosing is often in mcg/kg/min.
    • ALL Pediatric Dosing: Virtually every medication for a child is weight-based.
  3. The Intervention: If you encounter a weight-based order with a missing or implausible weight, you must place the order on hold. Your communication must be clear and direct.
    Pharmacist Note/Clarification to Provider:
    “Order for enoxaparin 1 mg/kg Q12H on hold. Patient does not have a documented weight in the chart. Please have nursing obtain and document an accurate weight so that a safe dose can be calculated and verified. Will process order once weight is available.”

18.5.2 Pitfall 2: The Non-Standard Concentration & The Broken Safety Net

Hospitals invest enormous resources in creating standardized drug concentrations for continuous IV infusions. This is a cornerstone of medication safety. These standard concentrations are built into the smart pump drug libraries, allowing for robust safety guardrails. When a provider orders a non-standard concentration (often by free-texting instructions in the Order Composer), they inadvertently bypass this entire, multi-million dollar safety net, creating a high-risk situation that only you can intercept.

18.5.2.1 The “Why” Behind Standardization

Standardization is about eliminating variables to reduce the chance of error. When every bag of norepinephrine in the hospital is 4 mg in 250 mL, it creates a predictable, safe system.

Benefit of StandardizationThe Risk of a Non-Standard Order
Smart Pump Library Match: The pump is pre-programmed to expect the standard concentration, allowing it to provide dose error reduction software (DERS). A custom concentration (e.g., 8 mg in 250 mL) will not match the pump library. The nurse must run the infusion in “basic” mode, manually programming the rate and bypassing all safety checks. The risk of a tenfold programming error increases exponentially.
Reduced Cognitive Burden: Nurses and pharmacists become experts at managing the standard drips. They know the typical rates and titration parameters instinctively. A non-standard drip requires every caregiver to stop and perform manual calculations, increasing the cognitive load and the chance of a math error, especially during a crisis.
Compounding Efficiency: The pharmacy can batch-prepare standard concentration bags, improving efficiency and ensuring product availability. Every non-standard bag must be custom-compounded STAT, delaying therapy and pulling resources away from other tasks.

18.5.2.2 Your Proactive Detection and Intervention Workflow

Spotting the “Free Text” Order

This is a key pattern recognition skill. Most standard orders are built from structured, clickable fields in Epic. When you see an IV order where the core instructions are typed into a “Special Instructions” or “Order Comment” field, it is a massive red flag. For example:

Medication: Norepinephrine in D5W
Dose: 16 mg
Instructions: “Please mix 16mg in 250mL of D5W and titrate to MAP > 65.”

This free-text instruction is a signal that the provider has likely created a non-standard product. Your job is to challenge this immediately.

  1. Identify the Deviation: Compare the ordered concentration to your hospital’s approved standard concentration list. Is it different?
  2. Question the Clinical Need: Is there an urgent, compelling clinical reason for this deviation? For example, in a severely fluid-restricted patient, a more concentrated drip might be necessary. This is rare. In 99% of cases, the standard concentration is the safest option.
  3. The Intervention: Your default action should always be to convert the order to the institutional standard.
    Pharmacist Note/Clarification to Provider:
    “Re: Norepinephrine order. The ordered concentration of 16mg/250mL is non-standard and will bypass our smart pump safety libraries. Our institutional standard is 4mg/250mL. Is there a specific clinical reason for the higher concentration (e.g., fluid restriction), or can I change this to our standard product to ensure maximum safety? The same dose/rate can be achieved.”

18.5.3 Pitfall 3: The Forgotten Flush & The Underdosed Patient

This is one of the most common and clinically significant errors of omission. When administering a small-volume IV piggyback (IVPB) or a critical electrolyte bolus through a primary IV line, a subsequent saline “flush” is required to push the entire dose from the IV tubing into the patient. If this flush is not ordered and administered, a significant portion of the drug can remain in the tubing, leading to a substantial underdose.

18.5.3.1 The Physics of the Problem: Dead Space

Standard IV tubing can hold a “dead space” volume of 15-25 mL. When a 50 mL IVPB of an antibiotic is infused, the entire volume of the bag enters the tubing, but without a subsequent flush, the last 15-25 mL of that dose remains in the tubing, never reaching the patient.

The Clinical Impact of Underdosing

  • For a Potassium Rider: If a patient is supposed to get 20 mEq of KCl in 100 mL, and 20 mL is left in the tubing, they have been underdosed by 20% (4 mEq). For a patient with critical hypokalemia, this can be the difference between successful repletion and persistent arrhythmia.
  • For an Antibiotic: A 30% underdose of a key antibiotic could lead to sub-therapeutic concentrations at the site of infection, promoting resistance and leading to treatment failure.

18.5.3.2 Your Proactive Detection and Intervention Workflow

Epic’s order sets are often built to include flushes automatically, but when providers enter orders manually, they are frequently forgotten. Your role is to be the “flush police.”

  1. Identify High-Risk Orders: Train your eyes to look for linked flushes on all orders that meet these criteria:
    • Any small-volume IVPB (typically ≤ 100 mL).
    • ALL IV electrolyte boluses (Potassium Chloride, Magnesium Sulfate, Calcium Gluconate).
    • Any intermittent IV medication where receiving the complete dose is critical.
  2. The Intervention: Adding the Linked Flush If you find a high-risk order without a linked flush, you must add one. Many institutions empower pharmacists to add flushes per protocol without contacting the provider. You will use the Order Composer to add a new order and link it to the primary medication.
    Primary Order: Potassium Chloride 20 mEq in 100mL NS IV x 1 dose.
    Your Added & Linked Order: Sodium Chloride 0.9% IV Flush 20 mL after infusion of Potassium Chloride.
  3. Documentation: If adding per protocol, a simple note suffices. “Linked flush added per pharmacy protocol.” This creates a clear record of your safety-focused intervention.