No products in the cart.
Case Study – Certified Hospital Pharmacy Operations Pharmacist (CHPOP)
CHPOP Interactive Case Studies
Certified Hospital Pharmacy Operations Pharmacist (CHPOP)
The Scenario: Verifying Orders for a Critically Ill Patient
It is a busy afternoon shift in the central pharmacy. A new patient has been admitted to the ICU from the Emergency Department with a diagnosis of urosepsis and acute kidney injury (AKI). A flood of new stat orders appears in your verification queue. As the CHPOP, you must rapidly assess the patient's profile and evaluate the safety and appropriateness of each order before it is dispensed.
Patient Profile and Order Queue
Patient Profile
- Patient: 68-year-old male, 100 kg
- Allergies: Penicillin (Anaphylaxis)
- Diagnosis: Urosepsis, Acute Kidney Injury
- Labs: SCr 3.5 mg/dL (baseline 1.1), K+ 5.8 mEq/L
Pending Electronic Orders
| Medication | Dose/Route/Frequency |
|---|---|
| Piperacillin-Tazobactam (Zosyn) | 4.5 g IV q6h |
| Vancomycin | 1500 mg IV q12h |
| Enoxaparin | 100 mg SUBCUT q12h |
| Potassium Chloride | 40 mEq IV Once |
Your Task
1. Identify the four medication orders that pose a significant safety risk as written and briefly state the primary problem with each.
Answer:
- Piperacillin-Tazobactam: The patient has a documented anaphylactic allergy to penicillin. This order is a direct contraindication.
- Vancomycin: The dose (1500 mg q12h) is a standard dose for a patient with normal renal function. In this patient with severe AKI (SCr 3.5), this dosing will lead to rapid supratherapeutic accumulation and toxicity.
- Enoxaparin: The dose (100 mg q12h, or 1mg/kg q12h) is a full treatment dose. It is not renally adjusted for the patient's AKI, which would result in bioaccumulation and a major bleeding risk.
- Potassium Chloride: Administering a 40 mEq IV bolus to a patient who is already hyperkalemic (K+ 5.8) with AKI (and thus cannot excrete potassium) is extremely dangerous and could precipitate a fatal cardiac arrhythmia.
2. What is the most appropriate action for the Piperacillin-Tazobactam order?
Answer:
The most appropriate action is to cancel the order and immediately contact the prescriber. You must inform them of the patient's documented anaphylactic allergy and recommend an alternative, non-beta-lactam antibiotic appropriate for urosepsis, such as ciprofloxacin or aztreonam, with the dose adjusted for the patient's acute kidney injury.
3. For the vancomycin order, what is the correct weight-based loading dose, and what is your plan for the maintenance dose?
Answer:
The correct loading dose is 2,500 mg, calculated using a standard 25 mg/kg dose for severe infections ($$25 \text{ mg/kg} \times 100 \text{ kg} = 2,500 \text{ mg}$$).
Maintenance Plan:
You should not order a scheduled maintenance dose. Given the severe and unstable renal function, the plan is "Pharmacist to Dose per Protocol." This involves obtaining a random vancomycin level 12-18 hours after the loading dose is complete. This level will be used to calculate the patient's specific elimination constant (Ke) and volume of distribution (Vd) to determine a safe and effective maintenance regimen.
The Scenario: Final Verification of a High-Risk CSP
You are the pharmacist responsible for the final check of compounded sterile products (CSPs). A technician hands you a clear plastic bin containing a chemotherapy IV piggyback for a pediatric patient, the compounding record, and the component vials. As the CHPOP, you are the final barrier to preventing a potentially catastrophic medication error. You must meticulously inspect every element to ensure 100% accuracy and safety.
Order, Record, and Product Information
Physician's Electronic Order
- Patient: Leo Sun, 4 years old, 18 kg
- Diagnosis: Rhabdomyosarcoma
- Order: Vincristine 1.0 mg in 50 mL 0.9% NaCl, IV Piggyback, Infuse over 10 minutes.
Compounding Record
| Ingredient | Amount Used |
|---|---|
| Vincristine 1mg/1mL Vial | 1.0 mL |
| Syringe Pulled Back to: | 1.0 mL |
Final Product Label on IV Bag
Patient: Sun, Leo
Drug: Vincristine 1.0 mg in 50 mL NS
Route: INTRAVENOUS
Ancillary Warning: "CHEMOTHERAPY - DISPOSE OF PROPERLY"
Beyond Use Date: [Tomorrow's Date]
Your Task
1. Upon reviewing all materials, you identify a critical, life-threatening omission on the final product label. What is it, and why is it so dangerous?
Answer:
The label is missing the mandatory, explicit warning: "FATAL IF GIVEN INTRATHECALLY - FOR IV USE ONLY." Vinca alkaloids like vincristine are neurotoxins. If accidentally administered into the spinal fluid (intrathecally), it is uniformly fatal. The generic "chemotherapy" warning is completely insufficient. ISMP and multiple other safety bodies mandate this specific, prominent warning on any dispensed syringe or bag of a vinca alkaloid to prevent this known type of catastrophic error.
2. The order, compounding record, and label all appear to have the correct dose of 1.0 mg. Is there another check you should perform before assuming the dose is correct? (Hint: Think about pediatric dosing).
Answer:
Yes. You must perform an independent dose verification against the patient's weight and the standard pediatric protocol. Vincristine is almost always dosed based on body surface area (mg/m²), and for pediatric patients, the dose is commonly capped at a maximum of 2 mg, regardless of calculation.
Dose Check:
A standard pediatric dose is 1.5 - 2 mg/m². This patient's BSA would be ~0.74 m². A standard dose would be closer to 1.1 mg. However, a flat 1.0 mg dose might be per a specific protocol. The key is that you cannot assume the ordered dose is correct; you must independently verify it. A quick check reveals that a dose of 1.0 mg for an 18kg child is reasonable and within safety limits, but the independent check itself is the mandatory step.
3. What are your immediate next steps after identifying the labeling error?
Answer:
- Do Not Dispense: Halt the verification process immediately.
- Quarantine the Product: Physically separate the IV bag so it cannot be accidentally dispensed.
- Correct the Label Template: This is a systemic error. Immediately go into the pharmacy computer system and update the master label template for all Vincristine products to include the mandatory "FATAL IF GIVEN INTRATHECALLY" warning.
- Reprint and Re-label: Print the corrected label and properly affix it to the IV bag.
- Educate the Technician and Staff: Speak with the compounding technician to explain the critical nature of this specific warning. Then, communicate the finding to all pharmacy staff to raise awareness of this safety check.
- Complete the Verification: Once the label is correct and all other checks are confirmed, sign off on the final product.
The Scenario: Hospital-Wide ADC Interface Failure
At 07:30, at the peak of the morning medication pass, the interface between your hospital's EHR and the entire network of Automated Dispensing Cabinets (ADCs) fails. New and modified orders are no longer being transmitted to the ADCs. Nurses can still access the machines by using the "override" function, but all patient-specific profiles are gone. The IT department estimates a fix will take at least 4-6 hours. As the on-call CHPOP, you must immediately orchestrate the pharmacy's response to this enterprise-level failure.
System Status and Capabilities
System Status
- EHR Order Entry: Online
- Pharmacy Verification System: Online
- ADC-EHR Interface: DOWN
- ADC Hardware: Online (in override mode)
ADC Override Functionality
- Bypasses all patient safety features (allergy, dose, interaction checks).
- Allows access to any medication in the cabinet.
- All overrides are logged by time and user, but NOT by patient.
Your Task
1. What is the single greatest patient safety risk during this downtime, and what is your first, most critical communication to nursing leadership?
Answer:
The greatest risk is a wrong drug, wrong dose, or wrong patient error due to the complete loss of patient-specific profiles and safety checks at the ADC. Nurses are essentially pulling medications blind.
Critical Communication:
Immediately communicate to nursing leadership to implement a downtime policy that requires a pharmacist verbal verification for all high-alert medications (e.g., insulin, anticoagulants, narcotics) removed on override. This re-introduces a critical safety check into the workflow before a potentially dangerous medication is administered.
2. The IT department restores the interface after 5 hours. What is the first and most critical report you must run from the ADC system, and what is its primary purpose?
Answer:
The first and most critical report is the Override Report for the entire 5-hour downtime period, for all ADCs in the hospital.
Primary Purpose:
Its primary purpose is reconciliation. This report is the only record of what was removed from the cabinets. You must reconcile every single line item on that report against a verified physician order in the EHR for a specific patient. This is essential to:
- Ensure all medications administered were appropriate and had a valid order.
- Identify any potential errors or diversions that may have occurred.
- Ensure all medications are correctly documented on the patient's electronic MAR.
- Ensure all medications, especially controlled substances, are accounted for to meet regulatory requirements.
3. This is the second major interface failure in three months. What long-term, systemic action must you initiate as a pharmacy leader?
Answer:
You must formally request and lead a Root Cause Analysis (RCA). A recurring critical system failure indicates a deeper, systemic problem that is not being addressed. The RCA is a formal process that brings together all stakeholders—pharmacy, nursing, IT, and the EHR and ADC vendors—to move beyond the immediate technical fix ("we restarted the server") and identify the true underlying cause of the instability. The goal of the RCA is to produce a binding Corrective and Preventive Action (CAPA) plan, with assigned owners and deadlines, to implement a permanent solution and prevent future failures.
