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CROVP Interactive Case Studies
Certified Remote Order Verification Pharmacist (CROVP)
The Scenario: Remote Verification of a High-Risk Order
You are a CROVP providing overnight coverage for a small, rural hospital. An order for an elderly patient in the ED appears in your queue. Your role is to perform a prospective order review, using the EHR to assess the order's safety and appropriateness before it is administered.
EHR Data & Order Information
New Medication Order
- Patient: 82-year-old male
- Order: Cefepime 2g IV every 12 hours
- Indication: Hospital-Acquired Pneumonia
EHR & Drug Database
- Patient History: Chronic Kidney Disease (CKD) Stage 4.
- Recent Labs: eGFR: 25 mL/min/1.73 m².
- Dosing Guideline: For eGFR 11-29 mL/min, the recommended cefepime dose is 1g IV every 24 hours.
Your Task
Task 1: What is the primary drug therapy problem with the new cefepime order?
Answer:
The problem is an inappropriate dose and frequency for the patient's level of renal function. The ordered dose (2g q12h) is a standard dose for a patient with normal kidneys, but this patient has severe CKD (eGFR 25).
Task 2: What is the potential clinical consequence if this order were administered as written?
Answer:
The patient would be at high risk for cefepime-induced neurotoxicity. Cefepime accumulates in patients with renal impairment, which can cause confusion, encephalopathy, and nonconvulsive status epilepticus (seizures).
Task 3: How does remote order verification improve patient safety in this setting?
Answer:
Remote verification provides 24/7 access to a pharmacist's clinical expertise. In a small hospital without an overnight on-site pharmacist, this order might have been administered without a safety check. The remote pharmacist acts as a critical safety net, catching dangerous prescribing errors before they reach the patient.
Task 4: What is your intervention and communication plan for this order?
Answer:
- Reject the Order: Pend the order in the EHR with a note: "Dose inappropriate for renal function. Please see pharmacist note or call."
- Contact Prescriber: Page or call the on-call physician.
- Provide Recommendation: "Dr. Davis, this is the remote pharmacist. Your order for cefepime 2g q12h on Mr. Smith is supratherapeutic for his eGFR of 25. The guideline-recommended dose is 1 gram IV every 24 hours. Would you like me to modify the order?"
- Document: Document the intervention and the physician's response in the EHR after the order is corrected.
The Scenario: Triaging a STAT Order Queue
It's 2 AM, and you are the sole remote pharmacist covering three hospitals. A "code blue" at one hospital and a new trauma admission at another cause your queue to fill with multiple STAT orders. You must prioritize which orders to verify first to prevent patient harm.
STAT Order Queue
| Priority | Hospital | Order | Patient Location |
|---|---|---|---|
| STAT | Hospital A | Epinephrine 1mg IV | ICU (Code Blue) |
| STAT | Hospital B | D50W 1 ampule IV | ED (Hypoglycemia) |
| STAT | Hospital A | Amiodarone 300mg IV | ICU (Code Blue) |
| STAT | Hospital C | Acetaminophen 650mg PO | Med/Surg (Headache) |
Your Task
Task 1: What is the core principle of triaging a STAT order queue?
Answer:
The principle is to prioritize based on the immediacy of clinical impact and potential for harm. The pharmacist must rapidly assess which order, if delayed by even a minute, poses the most immediate threat to a patient's life or limb.
Task 2: Rank these four STAT orders from highest priority (1st) to lowest priority (4th).
Answer:
- D50W for hypoglycemia.
- Epinephrine for Code Blue.
- Amiodarone for Code Blue.
- Acetaminophen for headache.
Task 3: Justify your choice for the #1 highest priority order.
Answer:
Severe hypoglycemia is an immediate threat to life, capable of causing irreversible brain damage or death within minutes if uncorrected. While the code blue is also critical, the medications for it are typically already available in a code cart for immediate nurse access, allowing a slight delay in formal verification. The D50W for a documented low blood sugar requires pharmacist verification before it can be pulled from the ADC and is therefore the most time-critical intervention.
Task 4: Justify why the Acetaminophen order is the lowest priority, even though it is marked "STAT."
Answer:
While the patient's pain is significant and should be treated promptly, a headache is not a life-threatening condition. The other three orders are for conditions that pose an immediate risk of death or serious harm (hypoglycemia, cardiac arrest). The pain medication can safely wait the few minutes it takes to process the life-saving therapies first. This demonstrates the pharmacist's clinical judgment in re-prioritizing orders that may be electronically flagged with the same level of urgency.
The Scenario: Communicating a Critical Intervention
You are remotely verifying orders when you see a new order for ketorolac IV for a post-operative patient. A quick review of the patient's chart reveals a significant contraindication. You must now contact the on-site surgical resident, who is known to be very busy and sometimes dismissive of pharmacy calls, to recommend a change.
Order & Patient Data
New Order
- Medication: Ketorolac 30mg IV q6h PRN pain
EHR Chart Review
- PMH: Peptic Ulcer Disease with GI Bleed 6 months ago.
- Recent Labs: SCr 1.8 mg/dL (eGFR ~35 mL/min)
- Communication Framework: SBAR (Situation, Background, Assessment, Recommendation)
Your Task
Task 1: What are the two absolute contraindications to ketorolac for this patient?
Answer:
1. History of GI Bleed: Ketorolac has a boxed warning for GI bleeding and is contraindicated in patients with a recent history. 2. Renal Impairment: Ketorolac is contraindicated in patients with advanced renal impairment (his eGFR is ~35 mL/min), as it can cause acute renal failure.
Task 2: Why is SBAR a critical communication tool for remote pharmacists?
Answer:
SBAR provides a standardized, predictable, and efficient framework for communicating urgent clinical information. For a remote pharmacist calling a busy, distracted provider, SBAR allows them to present a complex problem and a clear solution in under 60 seconds, which increases the likelihood the recommendation will be heard and accepted.
Task 3: Draft the "Assessment" portion of your SBAR communication.
Answer:
Assessment: "My assessment is that the ketorolac order is unsafe for this patient. It is contraindicated due to both his history of a GI bleed and his acute-on-chronic kidney injury."
Task 4: Draft the "Recommendation" portion of your SBAR communication.
Answer:
Recommendation: "I recommend we discontinue the ketorolac to avoid causing a bleed or worsening his kidney function. For his pain, safer alternatives would be scheduled IV acetaminophen or a low dose of an IV opioid like hydromorphone. Can I go ahead and enter an order for IV acetaminophen 1000mg q6h instead?"
