Transforming Order Transmission: Implementing a Pend and Send Workflow for Enhanced Clinical Practice

Electronic health records (EHR) have demonstrated their effectiveness in minimizing medical errors. However, the use of workarounds can introduce significant safety risks. A carveout in the hospital-based clinic (HBC) policy allowed cancer center nursing staff to sign orders under “transcribed/internal” mode. Non-providers use this order mode when entering orders into Epic on behalf of a provider. Orders entered this way are active immediately before the provider signs it and are subject to interpretation and transcription errors. Concerns related to physicians and nurses practicing outside of scope encouraged executive leadership to look at improvement opportunities to ensure patient safety and protect our medical staff by ensuring all were practicing within scope of their licensure.
This initiative aims to provide the safest care possible to our medical oncology patients by eliminating the gap in unsigned orders. The process of pending orders to providers was developed to ensure orders are reviewed for accuracy and signed by the provider before they are executed. Key stakeholders, including cancer center leadership, clinicians, nurse educators, workflow informaticists, and project management, met to develop an individualized, collaborative plan for each disease-oriented team (DOT).
Initially, executive health system leadership met with cancer center leadership, including project management, to assess compliance and patient safety concerns, review data, and partner to develop an action plan. Before each DOT go-live, the project team met to develop an implementation strategy with respective clinic leadership, including physician leaders. Education was then provided to each nursing team which included required Elsevier training to be completed before go-live. An Epic “pend and send” workflow was created allowing nurses to directly pend orders for signature to the provider via an Epic in-basket message.
Genitourinary (GU) medical oncology was the first DOT to go live in April 2024. A phased approach was utilized to implement the workflow in the remaining DOTs, with planned completion by November 2024. Before implementation in April, the cancer center averaged over 3,000 transcribed orders entered weekly. As of the end of September, the cancer center decreased transcribed internal orders by 50%. The partnership between the project team, physician leadership, and clinical team was critical to this project's success. A tailored approach to each DOT while focusing on the patient's safety and care was integral in the rollout of this initiative and helped increase buy-in from clinicians.