CHPPC Section 18.6: Guided Practice Set
Part 5: Data Entry & EHR Mastery (New Track)

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

18.6 Guided Practice Set: The Digital Proving Ground

Applying your comprehensive knowledge in a series of guided, high-fidelity clinical simulations to forge true “digital muscle memory.”

Welcome to the capstone of your Epic training. Theory has laid the groundwork, and deep dives have provided the blueprints, but it is only through deliberate, focused practice that true mastery is achieved. This final section is your clinical proving ground—a series of realistic, high-stakes inpatient scenarios designed to test and solidify every skill you have learned in this module. You will be placed in the digital hot seat, tasked with verifying some of the most complex and error-prone orders in hospital pharmacy. Each case is a comprehensive simulation, complete with a patient profile, a realistic (and flawed) Epic order, and a guided masterclass walkthrough. The goal is to move beyond simple knowledge and into the fluid, instinctual application of that knowledge—to build the “digital muscle memory” that separates a novice user from an expert clinical guardian. This is where your transformation into a confident, efficient, and exceptionally safe hospital pharmacist is finalized.

18.6.1 Case 1: The Heparin Protocol Initiation

A 62-year-old male (Height: 180 cm / 5’11”, Weight: 95 kg) is admitted with a new-onset, acute deep vein thrombosis (DVT) in his left leg. The medical team decides to start the hospital’s VTE Treatment heparin protocol. The following order appears in your verification queue.

18.6.1.1 Simulated Epic Order

VERIFY ORDER: Heparin (VTE Treatment) Protocol
PatientJONES, DAVID
MRN123456789
Patient Weight95 kg
AllergiesLisinopril (Cough)
Baseline SCr1.1 mg/dL
Baseline Platelets[NULL]
Order Set / ProtocolVTE Treatment Protocol – Heparin
Bolus Dose80 units/kg IV x 1
Initial Infusion Rate18 units/kg/hr
MonitoringOrder aPTT in 6 hours, then daily.

18.6.1.2 Your Task

Perform a complete clinical verification of this protocol initiation. Identify all safety concerns and omissions. Formulate your recommendations and determine the necessary actions before this high-alert medication can be safely started.

18.6.1.3 Masterclass Walkthrough

Step 1: Protocol Appropriateness & Initial Checks
  • Indication: Acute DVT is a correct indication for this protocol.
  • Allergies: Lisinopril allergy is irrelevant to heparin. No known heparin allergy.
  • Weight & Dose Calculation:
    • Bolus: 80 units/kg * 95 kg = 7,600 units. This is a standard VTE bolus.
    • Infusion: 18 units/kg/hr * 95 kg = 1,710 units/hr. This is a standard VTE initial rate.

The basic components and calculations of the order appear correct. The pitfalls, however, lie in what is missing from the patient’s data and the monitoring plan.

Step 2: Identifying Pitfall #1 – The Missing Baseline Platelets

This is a “Never-Event” Level Omission

Starting a heparin drip without a baseline platelet count is a major deviation from the standard of care. Heparin-Induced Thrombocytopenia (HIT) is a rare but catastrophic, life- and limb-threatening adverse reaction to heparin. It is an immune-mediated reaction where the body forms antibodies that activate platelets, leading to a paradoxical pro-thrombotic state and a precipitous drop in the platelet count.

A baseline platelet count is non-negotiable. It is the reference point against which all subsequent platelet counts will be trended to screen for HIT. Without it, you cannot diagnose a “50% drop from baseline,” which is a hallmark of HIT. This order must be placed on a hard hold until this lab value is resulted and reviewed.

Step 3: Identifying Pitfall #2 – Inadequate aPTT Monitoring

The therapeutic effect of heparin is monitored using the activated partial thromboplastin time (aPTT). The goal is to keep the aPTT within a therapeutic range (typically 1.5-2.5 times the control, or a specific second range like 60-100 seconds). The ordered monitoring is insufficient and unsafe.

Ordered MonitoringCorrect Monitoring ProtocolWhy It’s a Pitfall
“Order aPTT in 6 hours, then daily.” Order aPTT 6 hours after the initial bolus, AND 6 hours after *every* rate change, until two consecutive therapeutic aPTTs are achieved. Once stable, monitoring can be spaced out to daily. The ordered monitoring is dangerously infrequent. The initial dose is an estimate; the patient’s response is unknown. The aPTT must be checked frequently after initiation and any rate change to ensure the patient quickly reaches and stays in the therapeutic range, preventing both clotting (sub-therapeutic) and bleeding (supra-therapeutic). “Daily” monitoring is only for stable patients.
Step 4: Intervention and Documentation
  1. Immediate Action: Place the entire protocol order on hold. Do not verify any part of it.
  2. Communication with Provider: Contact the provider via Epic In Basket or phone.
    Pharmacist Note/Clarification to Provider:
    “Re: Heparin VTE Protocol for David Jones. Order is on hold for two safety issues:

    1. Missing Baseline Platelets: There is no baseline platelet count on file. This is required prior to heparin initiation to allow for safe monitoring for HIT. Please order a STAT CBC.

    2. Monitoring Frequency: The ordered aPTT monitoring (“Q6H then daily”) is not frequent enough for safe titration. Per protocol, aPTT should be checked 6 hours post-bolus and 6 hours after every rate change until stable.

    Please advise once baseline platelets are available for review. I can pend the corrected monitoring order for you to sign if you’d like. Thank you.”
  3. Post-Intervention Documentation: Once the provider responds and the baseline platelets are resulted and acceptable (>150,000/µL), you can proceed. Your final pharmacist note should be comprehensive.
    Pharmacist Verification Note:
    “10/04/2025 09:15 – Spoke with Dr. Evans. Baseline platelets resulted at 255,000/µL, safe to proceed. Provider verbally approved changing monitoring to standard VTE protocol (aPTT 6h post-bolus and 6h post-rate change until stable). Verbal order entered and signed. Heparin protocol now verified. [Your Name], PharmD. RBV.”

18.6.2 Case 2: The Insulin Drip & The Duplicate Dose

A 24-year-old female with a known history of Type 1 Diabetes is brought to the ED with altered mental status. Labs reveal a blood glucose of 580 mg/dL, an anion gap of 28, and positive serum ketones. She is diagnosed with Diabetic Ketoacidosis (DKA). The provider initiates the DKA protocol.

18.6.2.1 Simulated Epic Order

VERIFY ORDER: DKA Management Protocol
PatientWILLIAMS, SARAH
MRN987654321
Patient Weight65 kg
AllergiesNKDA
Initial Glucose580 mg/dL
Serum K+4.8 mEq/L

— DKA Protocol Orders —

1. IV FluidsNS at 1 L/hr x 2 hours, then 500 mL/hr
2. Insulin InfusionStart Regular Insulin drip at 0.1 units/kg/hr
3. MonitoringBlood glucose check Q1H. BMP Q4H.
4. Subcutaneous InsulinInsulin Glargine (Lantus) 20 units SubQ daily at 9pm

18.6.2.2 Your Task

Perform a complete clinical verification of this DKA protocol. The core components of the protocol itself seem correct. However, there is a major, dangerous therapeutic duplication hidden within the order set. Identify this pitfall and formulate your intervention.

18.6.2.3 Masterclass Walkthrough

Step 1: Protocol Appropriateness & Initial Checks
  • Indication: DKA is the correct indication for this protocol.
  • Initial Rate Calculation: 0.1 units/kg/hr * 65 kg = 6.5 units/hr. This is the standard initial rate for an insulin drip in DKA.
  • IV Fluids & Monitoring: Aggressive hydration and frequent lab checks are appropriate and essential components of DKA management.
  • Potassium Status: The patient’s initial K+ is normal. However, you must anticipate that insulin will drive potassium into the cells, causing hypokalemia. You must mentally flag this patient for potassium replacement, which is likely part of the nursing protocol for titration.
Step 2: Identifying Pitfall #1 – The Duplicate Insulin Administration

Unmasking the Hidden Danger of Therapeutic Duplication

The order for Insulin Glargine (Lantus) is the critical error. A patient on a continuous insulin infusion should NEVER receive concurrent long-acting subcutaneous insulin, unless it is part of a carefully planned transition protocol to turn the drip off. Administering both simultaneously is a dangerous therapeutic duplication that can lead to severe, unpredictable, and prolonged hypoglycemia, especially once the DKA begins to resolve.

Why does this happen? Often, a provider will use a pre-built “Admission Orders” set that includes restarting the patient’s home medications. The Lantus was likely the patient’s home insulin regimen and was inadvertently continued alongside the new, acute DKA protocol.

Step 3: The Clinical Rationale for Intervention

You must intervene to prevent this error. The rationale is clear and absolute:

  • Unpredictable Pharmacokinetics: The insulin drip provides a predictable, minute-to-minute titratable effect that can be stopped quickly if hypoglycemia occurs. The subcutaneous glargine provides a 24-hour basal effect that is non-titratable and cannot be “turned off” once administered. Having both active makes managing the patient’s glucose levels almost impossible.
  • High Risk of Delayed Hypoglycemia: As the insulin drip resolves the acidosis and hyperglycemia, the patient’s insulin requirements will drop dramatically. If a large depot of glargine is also on board, it will continue to exert its effect, leading to a high risk of a hypoglycemic crisis hours later.
Step 4: Intervention and Documentation
  1. Immediate Action: Verify the safe parts of the protocol (the IV fluids, the insulin drip itself, the monitoring) to allow therapy to begin immediately. Place the subcutaneous Insulin Glargine order on a hard hold.
  2. Communication with Provider: Contact the provider.
    Pharmacist Note/Clarification to Provider:
    “Re: DKA Protocol for Sarah Williams. The insulin drip and fluids have been verified and can be started.

    The order for Insulin Glargine (Lantus) 20 units SubQ daily has been placed on hold. Concurrent administration of long-acting subcutaneous insulin is contraindicated while a patient is on a continuous insulin infusion for DKA due to high risk of severe, prolonged hypoglycemia.

    Suggest discontinuing the Insulin Glargine order. The subcutaneous basal insulin can be re-initiated as part of the transition protocol once the anion gap is closed and the patient is ready to come off the drip. Please advise.”
  3. Post-Intervention Documentation: After the provider agrees and discontinues the order.
    Pharmacist Verification Note:
    “10/04/2025 10:30 – Verified DKA protocol. Placed Insulin Glargine order on hold due to therapeutic duplication with insulin infusion. Spoke with Dr. Chen, who agreed and has discontinued the glargine order. All other components of DKA protocol are now active. [Your Name], PharmD.”