CHPPC Module 26, Section 4: When to Park vs Push Back an Order
MODULE 26: QUEUE COMMAND: TIME-TRIAGE FOR VERIFICATION UNDER FIRE

Section 26.4: When to Park vs. Push Back an Order (and How to Communicate It)

The Art of the Holding Pattern: A Tactical Guide to Managing Incomplete, Ambiguous, and Unsafe Orders.

SECTION 26.4

When to Park vs. Push Back an Order

Mastering the critical workflow decision for every “problem” order you encounter.

26.4.1 The “Why”: Clearing the Runway for Safe and Efficient Flow

In a perfect world, every order that enters your queue would be complete, correct, and clinically appropriate. In reality, a significant percentage of orders are imperfect. They may be missing a minor detail, require clinical clarification, or be fundamentally unsafe. A common pitfall for new hospital pharmacists is not having a system for dealing with these “problem orders.” They might leave them sitting in the main queue, causing a bottleneck, or stare at them for minutes on end, unsure of the next step. This indecision grinds your workflow to a halt and can delay care for other patients.

Expert hospital pharmacists, like expert air traffic controllers, have a clear, binary system for any “aircraft” that cannot be immediately cleared for landing. They either place it in a safe holding pattern pending more information, or they wave it off and send it around for a completely new approach. In pharmacy, these two actions are “Parking” and “Pushing Back.”

Parking an order is the act of moving it to a separate, non-active queue while you asynchronously gather the missing information. Pushing Back (or rejecting/discontinuing) an order is the active, immediate cancellation of an order that is fundamentally unsafe. Knowing which action to take, and how to communicate it professionally, is a critical skill for maintaining a safe and efficient workflow. This section will provide you with a clear decision-making framework and the communication scripts to execute these actions with confidence.

26.4.2 The Analogy: The Professional Document Reviewer

A Deep Dive into the Analogy

Imagine you are a senior editor at a publishing house, and a stack of manuscripts lands on your desk for final approval. You are the last checkpoint before they go to print. You quickly realize that not all manuscripts are ready.

  • The “Missing Signature”: One manuscript is brilliant, but the author forgot to sign the final contract page. The entire book is sound, but you can’t proceed without this one piece of information. You don’t throw the book away. You put a sticky note on it that says, “Needs author signature on p. 342,” place it in your “Pending” tray, and send a quick email to the author. This is Parking an order. You are holding it pending a minor, correctable piece of information.
  • The “Fatal Flaw”: The next manuscript you pick up has a catastrophic problem. The entire third chapter contains plagiarized material, which is illegal and would destroy the firm’s reputation. You don’t put this in the pending tray. You take out a large red stamp, mark the cover “REJECTED,” attach a clear memo explaining the fatal flaw (“Chapter 3 contains plagiarized content and must be completely rewritten”), and send it back to the acquisitions editor with an urgent phone call. This is Pushing Back an order. You are actively rejecting a proposal that is fundamentally unsafe or inappropriate to proceed.

Your job as a pharmacist is to be this professional reviewer. You must learn to quickly distinguish between a “missing signature” (a missing PRN reason) and a “fatal flaw” (a 10-fold overdose) and apply the correct workflow to each.

Masterclass Part 1: The Art of the Holding Pattern — “Parking” an Order

“Parking” (also called “pending,” “profiling,” or “putting on hold,” depending on your EHR’s terminology) is your primary tool for managing orders that are likely correct but are missing a piece of non-critical information. The goal of parking is to clear the order from your active queue so you can focus on other priorities, while simultaneously initiating the process to get the information you need.

When to Park: The “Missing Information” Checklist

You should park an order when it is clinically plausible but administratively incomplete. Here are the classic scenarios:

ScenarioWhy Park It?
Missing PRN Indication/Frequency A PRN order for “Acetaminophen 650mg” is incomplete. The nurse can’t act on it. Park the order while you send a secure chat to the provider asking them to add “q6h PRN pain/fever.”
Non-Formulary Medication that has a Standard Interchange An order for “esomeprazole” (non-formulary) comes in. Your hospital has a pharmacist-driven interchange protocol to switch to “pantoprazole.” Park the original order, enter the new order for pantoprazole per protocol, and link them.
Needs Confirmation of a Home Dose A patient is admitted on levothyroxine, but the dose is unclear. This is an important medication, but missing one dose is not life-threatening. Park the order while you attempt to call the patient’s retail pharmacy.
Clinically Stable Patient, Order Needs a Non-Urgent Lab Check A provider orders allopurinol for a patient with a history of gout. It’s a reasonable order, but you want to confirm a baseline uric acid level was drawn. Park the order while you check the labs or message the provider.

The Mechanics of a Perfect “Park”

Simply moving an order to a pending queue is not enough. A “naked park” is dangerous because if you get distracted, no one else will know why it was parked. Every park must be accompanied by a clear note and an action.

  1. Initiate the Communication First: Before you even park the order, send the secure chat or make the phone call to get the information you need. This starts the clock on the resolution.
  2. Move the Order to the Pending Queue: Use your EHR’s function to place the order in a “pending” or “pharmacist review” status. This removes it from the main verification screen.
  3. Write a Clear, Actionable Note: This is the most critical step. The note must explain (1) what the problem is, and (2) what action you have taken. This allows any other pharmacist to understand the situation at a glance.
Communication Scripts for Parked Orders (The Accompanying Message)

SUBJECT: Jane Doe, Rm 602 – Clarification Needed for Tylenol Order

Hi Dr. Smith,

Could you please add a frequency and indication to the new order for Acetaminophen 650mg PO for Jane Doe?

I have parked the order in the meantime and will verify it as soon as it’s updated.

Thank you!

Masterclass Part 2: The Hard Stop — “Pushing Back” an Order

“Pushing Back” (rejecting, discontinuing, or cancelling) is one of your most important patient safety functions. It is an active, immediate refusal to process an order because it represents a clear and present danger to the patient. This is not a passive act; it is a powerful clinical intervention that must be followed by immediate communication.

When to Push Back: The “Clear and Present Danger” Checklist

You should push back an order when it is clinically indefensible and proceeding would violate your professional duty to do no harm. These are “stop the line” moments.

ScenarioWhy Push It Back?
Documented Severe Allergy An order for amoxicillin on a patient with a documented anaphylactic allergy to penicillin. This is an absolute contraindication.
Catastrophic Overdose A 10-fold or greater overdose of a high-risk medication (e.g., “morphine 20 mg IV” instead of “2 mg,” “warfarin 50 mg” instead of “5 mg”).
Dangerous Therapeutic Duplication A new order for a heparin infusion on a patient already receiving therapeutic enoxaparin. The risk of major hemorrhage is unacceptably high.
Fundamentally Unsafe Order An order for “IV potassium chloride 40 mEq IV PUSH.” This is a lethal injection and must be rejected instantly.
Order on the Wrong Patient You see an order for chemotherapy on a patient admitted for a broken leg. This is an obvious error that must be stopped immediately.

The Mechanics of a Professional “Push Back”

Pushing back an order requires both a system action and a human action. Failure to do both can be dangerous.

  1. Select “Discontinue” or “Cancel” in the EHR: Immediately take the action in the system to remove the order from the active profile.
  2. Write a Concise, Safety-Focused Reason: When the system prompts for a reason, be clear, professional, and non-punitive.
    • Bad Reason: “Wrong dose.”
    • Good Reason: “Potential 10-fold overdose. Please re-order at a safe dose. Paging now to clarify.”
  3. Initiate IMMEDIATE Communication: This is non-negotiable. You cannot silently reject a STAT order. You must immediately contact the ordering provider via a STAT page or direct phone call to inform them of the rejection and resolve the clinical issue.
Communication Script for a Pushed Back Order

(Via phone call to the ordering resident):

“Hi Dr. Davis, this is [Your Name], the pharmacist. I’m calling about your patient John Smith in room 314.

I had to push back the STAT order you just entered for morphine 20 mg IV. The standard dose is typically 2 mg, so I was concerned this might be a 10-fold overdose.

To be safe, I have cancelled the order. What dose would you like me to enter for the patient?”

Why this works: It’s immediate and direct. It states the action taken (“I had to push back…”). It clearly and calmly states the safety concern (“concerned this might be a 10-fold overdose”). It assumes good intent (framing it as a potential typo, not an act of incompetence). It ends with a collaborative solution (“What dose would you like me to enter?”).

Masterclass Part 3: The Gray Zone — A Comparative Guide

The decision between Parking and Pushing Back is one of the most common and critical judgments you’ll make. This table provides a head-to-head comparison to guide your thinking.

Factor Park the Order Push Back the Order
Core Problem Missing Information Clear and Present Danger
Order Status Clinically plausible, administratively incomplete. Clinically indefensible, fundamentally unsafe.
Your Goal Gather information to complete a likely-correct order. Prevent harm from a definitely-incorrect order.
Workflow Action Move to a “pending” queue; order is held. Discontinue/cancel the order; it is removed from the profile.
Communication Method Asynchronous (Secure Chat, non-urgent message). Synchronous & Immediate (STAT Page, direct phone call).
Guiding Analogy The “Missing Signature.” The “Fatal Flaw.”
Classic Example A PRN Tylenol order missing a frequency. An order for penicillin on a patient with a documented anaphylactic allergy.