Improved EHR Documentation Eliminates Heparin Errors

By Katie Wike, contributing writer

Staff education is one way Carilion Roanoke Memorial Hospital improved EHR documentation and eliminated dangerous heparin administration.

Carilion Roanoke Memorial Hospital (CRMH) encountered 17 patient harm events involving heparin infusions between January 2011 and June 2012. According to Health IT Analytics, only half of these were reported to the Joint Commission. CRMH attributes these incidents to poor staff education regarding heparin therapy.

A study presented at the Society of Health-System Pharmacists Summer Meeting found proactive monitoring of the infusion pumps combined with better staff education and EHR documentation was able to eliminate heparin errors. The study “showed that a lack of knowledge regarding heparin therapy among staffers, poor communication between departments and inadequate comprehension of the proper heparin titration protocol were among the major obstacles to improving how the anticoagulant was being managed in the hospital.”

“We learned that improvement was difficult because it involved a major commitment and a significant number of pharmacy hours,” study author Victor DeLapp, PharmD, BCPS, a medication safety clinical specialist in the Department of Pharmacy Services at CRMH said. “The one thing about education is [that] you have to maintain that level of knowledge on a consistent basis, especially with new hires, and we probably didn’t do a great job with that. [Additionally,] it wasn’t just our hospital that was suffering; I spoke with several colleagues who were also having a hard time dealing with similar problems.”

Since the hospital has implemented education programs and stricter EHR documentation rules, the number of heparin errors that resulted in patient harm has gone from 17 to 0. The program has completely eliminated heparin-related errors.

“Our approach is working, and it more than likely has applicability in other institutions,” DeLapp said. “It’s safe to say that our collaboration probably resulted in lives being saved, because with these medications, you never know when you’re going to have a serious bleed.”