Author: Alicia Beebe, MHA (2026)
Primary advisor: Angela Ross, DNP
Committee members: Erika Cavazos-Juarez, DHI and Kathy de Figueiredo, DHI
DHI Translational Project, McWilliams School of Biomedical Informatics at UTHealth Houston.
ABSTRACT
Medication safety remains a persistent challenge, particularly for high-risk anticoagulants where even minor communication failures can result in catastrophic bleeding or thromboembolic events. This translational project aimed to address the systemic risks associated with temporary medication holds in the electronic health record of a 10-hospital health system.
The project used a phased approach combining quantitative chart audits, qualitative clinician interviews, and workflow and cause mapping to examine anticoagulant medication-hold processes. Findings revealed design limitations, fragmented workflows, and usability challenges. Additionally, baseline analysis of September 2024 data revealed a substantial safety gap: Communication hold orders had a 15.05% medication error rate, compared with 0.13% for structured hold orders placed via a hold button.
Three interventions were applied to address system vulnerabilities identified in the anticoagulant medication-hold workflows. First, engagement with providers across multiple specialties promoted awareness of medication-hold risks and yielded feedback on the current workflow and proposed workflow redesign. Several participants from this group emerged as opinion leaders who supported use of the hold button for placing structured holds. Second, technical defects affecting task visibility, dispensing-cabinet integration, and advance-hold functionality were corrected. Third, a standardized future-state workflow was designed to reduce reliance on communication orders by embedding hold functionality within order sets.
Ordering trends showed a 160% increase in the use of the hold-order button from January to December 2024. Provider engagement, the first of the interventions, began in the last quarter of 2024 and may have contributed to the final months of this year-long trend. Additionally, the results of this project show promise for standardizing medication-hold processes for other high-risk medications and reinforce the need for interdisciplinary collaboration and iterative informatics improvements to enhance patient safety. Observations from this project highlight the potential role of structured workflows in supporting safer medication-hold processes in computerized provider order entry systems.
Keywords: Anticoagulants, CPOE, Human Factors, Medication Errors, Medication Holds, Swiss Cheese Model, Workflow Standardization