Nursing Associated Factors for Missed Doses of Pharmacologic Prophylaxis

Purpose: To minimize missed pharmacologic prophylaxis doses by investigating the reason with the bedside nurse or prescriber and determining if the institutional policy or evidence supports administration.

Implementation Process

Step 1. Bedside nurse documents a non-administered dose in the patient’s EHR, triggering an alert notifying the designee (often the charge nurse) carrying the pager/phone about the missed dose.

Step 2. Designee discusses the reason for the missed dose with the bedside nurse. If the missed dose is due to nurse, EHR, or prescriber factors, review recommendations in this section. If missed due to patient refusal, the Patient Education Bundle is delivered in real-time to the patient. (Follow link to Patient Education Bundle)

Note: Assessment and intervention in a timely manner may prevent the missed dose.

1. CONDITION NOT APPROPRIATE
It is prudent to critically assess whether the medication should be held or administered. Certain conditions may require holding a specific dose of pharmacologic prophylaxis. The best process is to notify the prescriber and document the action per your institutional policy.

A condition falls within acceptable hold parameters if it is either embedded in the order or described in an individual institution’s policy and procedures as an acceptable reason.

Examples of acceptable reasons:

• Active bleeding
• Low platelets
• Drug allergy
• Heparin-induced thrombocytopenia (HIT)

When there are concerns for a specific hold, notify the prescriber first and have them order a hold for that specific dose. If appropriate, the prescriber may discontinue the medication and initiate an order of appropriate VTE prophylaxis based on the patient’s changed risk assessment. Documentation of the changes in addition to handoff should be done.

Examples of unacceptable reasons:

• Patient ambulating
• Patient going home soon
• Patient asleep

2. HOLD FOR PROCEDURE
While pharmacologic VTE prophylaxis can be held for some procedures, the decision should be thoughtful not arbitrary. When you have concerns, contact the prescriber and ensure they place an appropriate corresponding order or discontinuation order. Also, implement appropriate prophylaxis alternatives. As above, follow your institution’s policy and procedures for communication and documentation.

Examples of acceptable reasons:

• Neurosurgery
• Spinal tap or block
• Some ocular procedures

Examples of unacceptable reasons:

• PICC line or central line placement
• Epidural placement/removal: Providers should schedule removal for an appropriate timeframe around dose, as opposed to missing a prescribed dose.
• Many surgical, interventional radiology procedures and endoscopy

For many surgical interventions, heparin is administered in the operating room after epidural placement and before skin incision.

If the provider requests the hold, make sure there is a corresponding hold order in your system. 

3. ELECTRONIC HEALTH RECORD ISSUES
Some common EHR-related issues are order sets that overlap, transfers, and reordering prophylaxis in the EHR. There may be duplicate orders that appear in the medication administration record (MAR). At times, these orders may be documented as a “duplicate order” in both slots, resulting in the medication not being administered. Carefully double check these types of orders to prevent miscommunication or missed doses.

Charted in error
In some EHRs “charted in error” will complete a medication and, if not addressed or followed, the medication will “fall” off the MAR as being done.

Unreviewed orders
Some institutions require a pharmacist review of medication orders before release of the medication. If the review is delayed, the medication cannot be released, which may delay or contribute to a missed dose.

4. PATIENT DISCHARGED
Patient discharge may be an option in the EHR. Take care to only choose this option if the discharge log in the EHR notes the patient has actually left the institution. Doses administered on the day of discharge may be as important as doses administered at other time points in the patient’s hospital stay. Thus, it is important to ensure that the patient receives all of their prescribed doses of VTE prophylaxis. 

5. PATIENT NOT AVAILABLE
At times, a patient may be off the floor for testing or treatment (e.g., hemodialysis, imaging), or inaccessible due to a dressing change. Follow your institutional policies that address the appropriate timing for administering the VTE prophylaxis dose – either before the procedure or as soon as possible when the patient becomes available. If the dose is missed, notify the prescriber and document the missed dose.

When dealing with EHR issues, assess whether the patient actually received the dose. If not received, ensure that it is administered and correct the documentation.