The Inherent Dangers Of Order Sets

Document Type

Conference Proceeding - Restricted Access

Publication Date



A 57-year-old male was admitted to the surgical ICU for a complicated post-surgical course. Due to high risk of DVT formation, he was placed on a heparin infusion with q2hr neuro checks. On POD2, a surgical resident deleted duplicate orders for the patient, and inadvertently included an order set which included the heparin, therefore the infusion and neuro evaluations stopped. In this case discussion, we will explore the desensitization of medical health providers to the amount of information inherent to the EMR and the pitfalls of order sets that lead to iatrogenic errors.


American Society of Anesthesiology, Anesthesiology 2019. Orlando, FL. October 19-23, 2019.