CCPP Module 26, Section 1: Comprehensive Review of Core Competencies
MODULE 26: CAPSTONE, CERTIFICATION, AND CAREER ADVANCEMENT

Section 26.1: Comprehensive Review of Core Competencies

Synthesizing Knowledge into Mastery: A Capstone Review for the Collaborative Practice Pharmacist.

SECTION 26.1

Comprehensive Review of Core Competencies

Unifying disparate skills into a cohesive framework of expert clinical practice.

26.1.1 The “Why”: From Specialist to Systems Architect

Throughout your pharmacy career, and indeed throughout this certification program, you have accumulated a vast and diverse set of specialized skills. You are a pharmacologist, a kineticist, a dispenser, a counselor, a navigator of regulations, and a medication safety expert. You have mastered the intricate details of individual disease states, drug classes, and patient care protocols. Each module of this CCPP program was designed to build a distinct “room” of expertise in your professional knowledge base: the ICU room, the oncology clinic room, the anticoagulation management room, the regulatory compliance room.

This capstone review is not about building another room. It is about stepping back and looking at the master blueprint of the entire structure you have built. The goal of this section is to transition your thinking from that of a specialist working within a single room to that of a systems architect who understands how every room connects. You will see how the “plumbing” of pharmacokinetics impacts the “electrical systems” of pharmacology, how the “structural supports” of regulatory law dictate the layout of clinical practice, and how the “HVAC” of interprofessional communication ensures the entire system functions effectively for the patient at its center.

This is the final and most critical evolution in your journey to becoming a Certified Collaborative Practice Pharmacist. Mastery is not merely knowing what to do in a given situation; it is understanding why you are doing it in the context of the entire healthcare ecosystem. It is the ability to stand at the intersection of complex pharmacology, fluctuating patient physiology, and operational realities, and design a therapeutic plan that is not just correct, but optimal, safe, and sustainable. This comprehensive review will forge the connections between everything you have learned, solidifying your knowledge base and preparing you for the most complex challenges you will face in your advanced practice role.

Pharmacist Analogy: The Master Blueprint

Imagine an architect who has spent years designing individual, perfect rooms. One room is a state-of-the-art kitchen (your infectious disease knowledge), another a serene master bedroom (your cardiology expertise), and another a hyper-functional home office (your regulatory understanding). Each room, on its own, is a masterpiece of design and function.

However, a collection of perfect rooms does not make a functional house. Without a master blueprint, the kitchen’s plumbing might conflict with the office’s electrical wiring. The bedroom’s load-bearing wall might not align with the foundation. The hallways might lead to dead ends. The true genius of the architect is not just in designing the rooms, but in creating the blueprint that integrates them into a single, cohesive, and livable home.

This is your current position. You possess the expertise to design the “rooms.” This capstone review provides the master blueprint. We will trace the “wiring” of a single patient case as it travels from the ED (Module 22), to the ICU (Module 32), to the medical floor, and finally to your ambulatory care clinic for discharge follow-up (Module 15). You will see how a medication decision made in one “room” has profound implications in another. You will learn to anticipate these connections, to design patient care plans that are not just excellent in the moment but are robust and safe across the entire continuum of care. You are no longer just a room designer; you are the architect of the patient’s entire therapeutic journey.

Domain I: The Foundations of Collaborative Practice

This domain is the bedrock upon which all your clinical activities are built. Without a deep understanding of the legal, regulatory, and professional frameworks governing your practice, even the most brilliant clinical insights are useless. This is the “zoning and permitting” phase of our architectural analogy—it defines what you are allowed to build and how you must build it to be safe and legal.

High-Yield Flash Review: Legal & Regulatory Frameworks

  • Collaborative Practice Agreement (CPA): A formal agreement between a pharmacist(s) and a provider(s) that delegates specific patient care functions, including initiating, modifying, and discontinuing medication therapy. This is your foundational legal document.
  • Scope of Practice: Defined by state law and institutional policy (via credentialing and privileging). It dictates the ceiling of your professional activities. Your CPA can only delegate tasks that fall within the pharmacist’s scope of practice in your state.
  • Credentialing & Privileging: The internal hospital or health-system process of verifying your qualifications (license, education, training – credentialing) and granting you permission to perform specific tasks within that facility (privileging). This is how an institution operationalizes your scope of practice.
  • Liability: Under a CPA, liability is typically shared. Both the pharmacist and the collaborating provider are responsible for the care provided. Malpractice insurance must explicitly cover these advanced-practice activities.

Deep Dive Synthesis: The Interplay of State Law, CPAs, and Hospital Privileges

It is a critical error to view these concepts in isolation. They form a hierarchy of permission that you must navigate. Imagine you want to manage heparin drips for VTE treatment.

  1. State Law (The Foundation): First, you must ask: Does my state’s Pharmacy Practice Act permit pharmacists to initiate and modify medication orders under a CPA? Some states are very permissive, allowing broad delegation. Others are restrictive, listing specific diseases or drugs that can be managed. If the state law says “no,” the process stops here.
  2. The Collaborative Practice Agreement (The Contract): Assuming the state law allows it, you and your collaborating physician/service must create a CPA. This document must be exquisitely detailed. It will not just say “manage heparin.” It will specify the protocol to be used (e.g., the institutional weight-based nomogram), the initial bolus and infusion rate calculations, the frequency of aPTT monitoring, the specific dose adjustments for sub- or supratherapeutic aPTTs, and the criteria for notifying the physician. This CPA is your specific set of instructions.
  3. Institutional Privileging (The Permission Slip): You cannot simply sign a CPA and start managing heparin. You must submit your CPA and your credentials (e.g., this CCPP certification) to the hospital’s credentialing committee (often part of the medical staff office). They will review your qualifications and the CPA. If approved, they will grant you clinical “privileges” to perform the functions outlined in the CPA. This is the institution’s official blessing and is what allows you to enter orders in the EHR under your own name. Without privileges, you can only make recommendations, not write orders.
Critical Pitfall: The “Hallway Consult” vs. The Privileged Action

A common trap for new collaborative practice pharmacists is acting on informal agreements. A physician might say, “Hey, can you just handle all the dosing for my vancomycin patients?” While well-intentioned, this verbal request is not a substitute for a formal, credentialing-committee-approved CPA and granted privileges. If you make dose adjustments based on this “hallway consult” and an adverse event occurs, you may be practicing outside the scope of your institutional privileges and could face significant legal and professional jeopardy. If it’s not in your approved CPA and privileges, you can only recommend, not order. Document everything.

Domain II: Inpatient Clinical Mastery – The Core Disease States

This is the heart of hospital practice—managing acute, complex, and rapidly evolving disease states. Your role is to apply deep pharmacologic knowledge under pressure, integrating patient-specific data to optimize therapy in real-time. We will revisit the pillars of inpatient medicine, focusing on the synthesis of concepts.

26.1.2 Deep Review: Cardiology

Cardiology is a specialty of calculated risks and guideline-driven precision. Your mastery here depends on understanding the interplay between antiplatelets, anticoagulants, hemodynamics, and neurohormonal antagonism.

High-Yield Flash Review: Key Cardiology Concepts
  • Acute Coronary Syndromes (ACS): DAPT (Aspirin + P2Y12 inhibitor) is cornerstone. Choice of P2Y12i (clopidogrel, ticagrelor, prasugrel) depends on strategy (medical vs. PCI) and patient factors (age, stroke history). Add anticoagulant (heparin, enoxaparin) during acute phase. High-intensity statin is mandatory.
  • Heart Failure with Reduced Ejection Fraction (HFrEF): Four Pillars of Guideline-Directed Medical Therapy (GDMT): 1) ARNI/ACEi/ARB, 2) Evidence-Based Beta-Blocker, 3) MRA, 4) SGLT2 Inhibitor. Titrate to target doses as tolerated.
  • Atrial Fibrillation (AFib): Two main goals: rate control (beta-blocker, non-dihydropyridine CCB) and stroke prevention (anticoagulation). Stroke risk is assessed with CHA₂DS₂-VASc score; bleed risk with HAS-BLED. DOACs are first-line over warfarin.
Cardiology Synthesis Scenario: The Triple Threat Patient

Case: A 78-year-old male with a history of HFrEF (EF 30%) and paroxysmal AFib on apixaban 5 mg BID presents to the ED with chest pain. ECG and troponins are consistent with an NSTEMI. He is hypotensive at 92/60 mmHg and has crackles in his lungs. The team plans for a cardiac catheterization in the morning.

Pharmacist’s Integrated Thought Process

This single patient forces you to synthesize your knowledge of ACS, HF, and AFib simultaneously. Here is your mental checklist:

  1. ACS Management (The Immediate Problem):
    • – DAPT: He needs it now. Load with Aspirin 324 mg. Which P2Y12i? Ticagrelor is often preferred in NSTEMI. But what about his bleed risk, given he’s already on apixaban? This is “triple therapy.” The risk is high. You must discuss this with the team. The plan will likely be to hold the P2Y12i load until after the cath, once the coronary anatomy is known. Your job is to raise this safety concern.
    • – Anticoagulation for NSTEMI: He needs parenteral anticoagulation. A heparin drip is the standard choice, especially pre-cath. But he’s on apixaban. When was his last dose? You must find out. If it was recent, starting heparin could be dangerous. The protocol is often to hold parenteral anticoagulation if the last DOAC dose was within 12-24 hours. You are the DOAC expert; you must provide this guidance.
  2. HF Management (The Hemodynamic Problem):
    • – He is in acute decompensated heart failure (wet and cool). He needs diuresis (IV furosemide). What’s his home dose? You’ll likely need to give 2-2.5x his oral home dose IV.
    • – What about his GDMT? His beta-blocker should likely be held or dose-reduced given the hypotension and decompensation. His ARNI/ACEi should definitely be held. You must review his home med list and recommend holding these medications to prevent clinical worsening.
  3. AFib Management (The Peri-procedural Problem):
    • – Apixaban: This needs to be held before the cath to allow for femoral/radial access. You must provide the team with the exact timing based on renal function (e.g., hold for 24-48 hours).
    • – Bridging: Does he need heparin bridging for his AFib? Given he is getting a heparin drip for his NSTEMI, the question is moot for now. But post-procedure, you will need to devise a plan to safely restart his apixaban and DAPT, minimizing the duration of triple therapy. This post-procedure transition plan is a key pharmacist responsibility.

26.1.3 Deep Review: Infectious Diseases

ID is the ultimate detective work in pharmacy. It requires a mastery of microbiology, pharmacology, and patient-specific factors to solve the case of the invading pathogen. Your synthesis here involves moving from simply choosing a drug to designing a comprehensive antimicrobial strategy.

High-Yield Flash Review: Key ID Concepts
  • The “Big Three” Buckets of Bacteria: 1) Gram-positives (Staph, Strep, Enterococcus), 2) Gram-negatives (E. coli, Klebsiella, Pseudomonas), 3) Anaerobes (Bacteroides). Your empiric regimen must cover the likely pathogens from these buckets based on the source of infection.
  • Antimicrobial Stewardship: The five core principles: 1) Right Drug, 2) Right Dose, 3) Right Route, 4) Right Duration, 5) De-escalation.
  • PK/PD Optimization: Maximizing bacterial killing by leveraging pharmacokinetics. Time-dependent (Beta-lactams – maximize Time>MIC) vs. Concentration-dependent (Aminoglycosides, Vancomycin – maximize Cmax/MIC or AUC/MIC).
ID Synthesis Scenario: Septic Shock with a Complication

Case: A 65-year-old female with CKD stage 3 (eGFR ~45 mL/min) is admitted from a nursing home with septic shock from a suspected UTI. She has a history of a non-anaphylactic rash to amoxicillin. The ED starts the Sepsis Bundle. You are the pharmacist verifying the orders.

Pharmacist’s Integrated Thought Process
  1. Empiric Antibiotic Selection:
    • – Source: UTI from a nursing home. This means we worry about more resistant organisms than a simple community UTI. This is Healthcare-Associated. Likely pathogens include E. coli, Klebsiella, but also potentially Pseudomonas and Enterococcus.
    • – The Allergy: A rash to amoxicillin is not a true contraindication to all beta-lactams. There is very low cross-reactivity between penicillins and cephalosporins or carbapenems. You do not need to avoid them. Your role is to educate the team that a cephalosporin is safe and appropriate. A fluoroquinolone would be a poor choice due to high resistance rates.
    • – The Regimen: Standard ceftriaxone may not be broad enough for a nursing home UTI. You need anti-pseudomonal coverage. Cefepime is an excellent choice. Does she need MRSA coverage? For urosepsis, typically not, unless there is a specific risk factor (like prior MRSA UTI). Does she need Enterococcus coverage? Cefepime does not cover it. If the patient is extremely ill, adding ampicillin or vancomycin might be considered, but for most, cefepime alone is a great start. Your recommendation should be Cefepime.
  2. Dosing and PK/PD Optimization:
    • – Renal Dosing: This is the most critical step. Cefepime requires renal dose adjustment. For an eGFR of 45, a standard dose of 2g q8h is too high and risks neurotoxicity. You must look up the correct dose (e.g., 2g q12h). You are the safety net that prevents this dosing error.
    • – Prolonged Infusion: Cefepime is a time-dependent beta-lactam. For a critically ill patient in septic shock, you should strongly advocate for a prolonged infusion (e.g., infusing each dose over 4 hours) to optimize the Time>MIC and improve outcomes. This is an advanced practice recommendation that demonstrates your mastery.
  3. The Stewardship Plan (Thinking Ahead):
    • – Your job isn’t done after verification. You must write a note in the chart outlining your plan: “Initiated renally adjusted, prolonged-infusion cefepime for healthcare-associated urosepsis. Will follow up on urine and blood cultures in 48 hours to de-escalate therapy. Recommend a 7-day total course of therapy pending clinical improvement.” This proactive planning is the hallmark of a stewardship champion.

26.1.4 Deep Review: Critical Care

The ICU is an environment of controlled chaos where physiology changes by the minute. Your role is to manage the potent medications that support life, ensuring they are used safely and effectively, and to anticipate and prevent medication-related complications.

High-Yield Flash Review: Key Critical Care Concepts
  • Hemodynamics: MAP = CO x SVR. The goal is a MAP > 65 mmHg to ensure organ perfusion. Shock is classified by its cause: Distributive (low SVR, e.g., sepsis), Cardiogenic (low CO, e.g., MI), Hypovolemic (low preload).
  • Vasopressors: First-line for septic shock is Norepinephrine (potent alpha-1, moderate beta-1). Add Vasopressin (V1 agonist) as a second agent. Epinephrine is used in refractory shock or cardiogenic shock.
  • Sedation & Analgesia: The “Analgesia-first” principle. Treat pain (fentanyl, hydromorphone) before sedating. For sedation, Propofol (fast on/off, causes hypotension) and Dexmedetomidine (doesn’t cause respiratory depression, causes bradycardia/hypotension) are workhorses. Use the RASS score to target light sedation.
Critical Care Synthesis Scenario: The Post-Op Spiral

Case: A 70-year-old patient is in the ICU post-op from a major abdominal surgery. He is intubated and on a fentanyl drip for pain and a propofol drip for sedation. Overnight, his blood pressure drops, and he is started on a norepinephrine drip. His MAP is stable, but now his triglycerides are noted to be 550 mg/dL and his urine is green.

Pharmacist’s Integrated Thought Process

This scenario requires you to connect the dots between sedation choices, their metabolic side effects, and the patient’s hemodynamic status.

  1. Identify the Core Problem: The patient has two classic signs of Propofol-Related Infusion Syndrome (PRIS) or at least propofol-induced hypertriglyceridemia. The green urine is a known, benign metabolite of propofol, but the rising triglycerides are a major concern and a harbinger of PRIS, which can lead to rhabdomyolysis, cardiac failure, and death. You must be the first to recognize this toxidrome.
  2. Assess the Hemodynamics: The patient is on norepinephrine. Propofol is a known vasodilator and negative inotrope; it is contributing to his hypotension and increasing his vasopressor requirement. The sedation is actively working against the resuscitation.
  3. Formulate a Recommendation (The SBAR): You need to call the ICU team with a clear, actionable plan.
    • – (S)ituation: “Dr. Smith, I’m calling about your patient in bed 5. I’m concerned about his sedation. His triglycerides have risen to 550 and he has a high and increasing norepinephrine requirement.”
    • – (B)ackground: “He has been on a propofol infusion at a relatively high dose for over 24 hours. The combination of hypertriglyceridemia and hemodynamic instability is highly suggestive of propofol-related toxicity.”
    • – (A)ssessment: “I believe the propofol is causing his hypertriglyceridemia and contributing significantly to his shock state. Continuing it poses a risk of progressing to full PRIS.”
    • – (R)ecommendation: “I recommend we stop the propofol immediately and switch his sedation to dexmedetomidine. It will provide adequate sedation without the lipid issues and may allow us to wean his norepinephrine more quickly. We should also check a CPK to screen for rhabdomyolysis.”
  4. Execute the Transition: Once the team agrees, your job is to facilitate a safe transition. This involves guiding the nurse on how to titrate down the propofol while titrating up the dexmedetomidine to maintain the target RASS score without a period of inadequate sedation.

Domain III: Ambulatory & Specialty Clinic Mastery

In the ambulatory setting, the focus shifts from acute resuscitation to chronic disease management, patient education, and long-term optimization. Your role is that of a primary care partner, managing complex medication regimens over months and years, empowering patients to be active participants in their own care.

26.1.5 Deep Review: Anticoagulation Clinic

High-Yield Flash Review: Key Anticoagulation Concepts
  • Warfarin: Vitamin K antagonist. Narrow therapeutic index, requires routine INR monitoring. Affected by diet (vitamin K) and countless drug interactions (CYP2C9, etc.). Your role is dosing, monitoring, and extensive education.
  • DOACs: Direct Thrombin Inhibitors (dabigatran) and Factor Xa Inhibitors (rivaroxaban, apixaban, edoxaban). Fewer interactions, no routine monitoring. Your role is patient selection, counseling on adherence, renal dose adjustments, and peri-procedural management.
  • Peri-procedural Bridging: The process of stopping chronic oral anticoagulation for a procedure and using a short-acting parenteral agent (enoxaparin, heparin) to “bridge” the gap. The decision to bridge is based on balancing thrombosis risk (e.g., CHADS-VASc, mechanical valve) against procedural bleed risk.
  • Reversal Agents: For life-threatening bleeds. Warfarin: Vitamin K + Kcentra (4F-PCC). Dabigatran: Idarucizumab (Praxbind). Factor Xa Inhibitors: Andexanet alfa (Andexxa).
Anticoagulation Synthesis Scenario: The Bridging Conundrum

Case: You are managing two patients in your anticoagulation clinic who both need a colonoscopy next week.
Patient A: 68-year-old male on warfarin for a mechanical mitral valve. INR is stable at 2.8 (goal 2.5-3.5).
Patient B: 72-year-old female on apixaban 5 mg BID for AFib (CHA₂DS₂-VASc = 4). CrCl is 70 mL/min.

Pharmacist’s Integrated Management Plan

This requires you to create two completely different, highly detailed peri-procedural plans, demonstrating your mastery of both old and new anticoagulants.

Management Plan for Patient A (Warfarin, High Thromboembolic Risk)
  1. Risk Assessment: Mechanical mitral valve is a high-risk condition for thrombosis. The bleed risk of a colonoscopy with potential biopsy is moderate-to-high. This patient requires bridging therapy.
  2. The Written Plan (Patient Instructions):
    • – “5 days before your procedure (on Saturday), stop taking your warfarin.“
    • – “3 days before your procedure (on Monday), you will start injections of enoxaparin. Your dose will be [calculate weight-based therapeutic dose, e.g., 1 mg/kg] injected under the skin every 12 hours.” You must provide full injection training.
    • – “Take your last dose of enoxaparin on the evening before your procedure. Do not take the enoxaparin dose on the morning of your procedure.”
    • – “After your colonoscopy, the doctor will tell you when it is safe to restart anticoagulation. You will likely restart your enoxaparin injections and your usual dose of warfarin that evening.”
    • – “You will need to continue both the enoxaparin injections and the warfarin pills for several days until your INR is back in the target range (at least 2.5). You must come to the clinic for daily INR checks starting the day after the procedure.”
  3. Provider Communication: You must communicate this detailed plan to both the patient’s gastroenterologist and their cardiologist to ensure everyone is in agreement.
Management Plan for Patient B (DOAC, Moderate Thromboembolic Risk)
  1. Risk Assessment: AFib with a CHADS-VASc of 4 is a moderate-to-high thrombosis risk. However, modern guidelines recommend AGAINST routine bridging for DOACs in most situations due to increased bleeding without a clear benefit in stroke reduction. The short half-life of apixaban is sufficient.
  2. The Written Plan (Patient Instructions):
    • – “For a standard-risk procedure like a colonoscopy, you will need to stop your apixaban 48 hours before the procedure.” (Provide the exact date and time of the last dose).
    • – “You do not need to take any shots.”
    • – “After your procedure, the doctor will tell you when it is safe to restart. You can typically restart your apixaban 5 mg twice daily that evening, as long as there is no bleeding.”
  3. Provider Communication: Your key role here is often to educate the proceduralist. Many providers are still accustomed to the old warfarin/bridging paradigm and may incorrectly ask the patient to bridge. You must confidently state: “Per current guidelines for patients on DOACs undergoing this procedure, bridging with enoxaparin is not recommended and may increase bleeding risk. A simple 48-hour hold of apixaban is the standard of care.”
Critical Pitfall: One Size Does Not Fit All

The single greatest error in peri-procedural management is applying a “one size fits all” approach. Applying a warfarin bridging strategy to a DOAC patient is unnecessary and dangerous. Failing to bridge a mechanical mitral valve patient is equally dangerous. Your value as a collaborative practice pharmacist lies in your ability to create a bespoke plan for each patient based on their specific anticoagulant, their underlying thrombotic risk, and their procedural bleeding risk.

Domain IV: Operational & Regulatory Competencies

Excellent clinical care must be delivered within a system that is safe, efficient, and financially sustainable. This domain focuses on the non-clinical skills that are essential for a successful collaborative practice: ensuring patient safety through systems analysis and demonstrating your value through appropriate billing and documentation.

26.1.6 Deep Review: Medication Safety & Root Cause Analysis

Your role extends beyond preventing errors at the individual patient level. As a CCPP, you are a leader in medication safety, responsible for analyzing errors when they occur and helping to build more robust systems to prevent them from happening again.

High-Yield Flash Review: Key Safety Concepts
  • Root Cause Analysis (RCA): A structured, retrospective method for analyzing a serious adverse event. It is NOT about blaming individuals. It is about identifying the underlying system flaws (latent errors) that allowed the mistake to happen.
  • The “5 Whys”: A simple technique used in an RCA. For every apparent cause, ask “Why?” repeatedly until you arrive at the fundamental process or system failure.
  • Just Culture: A safety culture that distinguishes between human error (a slip), at-risk behavior (taking a shortcut), and reckless behavior (disregarding known risk). It encourages reporting by not punishing human error, but holds individuals accountable for their behavioral choices.
  • Failure Mode and Effects Analysis (FMEA): A proactive risk assessment tool. Instead of analyzing an error that happened, you prospectively analyze a process (e.g., a new chemo regimen rollout) to identify potential failure points and build safeguards before they occur.
Safety Synthesis Scenario: The Wrong-Dose Chemotherapy Event

Case: A patient with renal dysfunction (CrCl 25 mL/min) received a full dose of carboplatin, which should have been renally dose-adjusted. The patient develops severe, life-threatening myelosuppression. You are asked to lead the RCA.

Pharmacist-Led Root Cause Analysis

A non-systems approach would be to blame the ordering physician or the verifying pharmacist. A CCPP-led RCA goes much deeper using the “5 Whys.”

  1. Why did the patient get the wrong dose? Because an unadjusted dose was ordered and verified.
  2. Why was it ordered and verified? The physician used a standard order set that didn’t automatically calculate the renal adjustment, and the pharmacist’s verification screen didn’t flag the CrCl as being critically low for this specific drug.
  3. Why didn’t the order set calculate the dose? Because the EHR build for that order set lacked an integrated, mandatory Calvert formula calculator. It was just a free-text dose field.
  4. Why didn’t the pharmacist’s screen flag the issue? The clinical decision support (CDS) rules were too generic. There was a general “renal dosing” warning, but not a drug-specific “hard stop” alert for chemotherapy agents requiring adjustment based on a specific formula.
  5. Why were the order set and CDS rules inadequate? Because when the system was implemented, there was insufficient pharmacist involvement in the design and testing of high-risk medication order sets. The process lacked a key stakeholder. (This is the Root Cause).
The Action Plan (The Result of the RCA)

Based on this RCA, your recommendations are not about “re-educating the staff.” They are about fixing the system:

  • Immediate Fix: Rebuild the carboplatin order set to include a mandatory, embedded Calvert formula calculator that automatically pulls the patient’s SCr and calculates the correct dose.
  • System-Level Fix: Create a new hospital policy that requires a clinical pharmacist specialist (e.g., oncology pharmacist) to review and approve the build of all new chemotherapy and other high-risk medication order sets before they can go live in the EHR.
  • Culture Fix: Share the de-identified findings of the RCA with the pharmacy and medical staff, emphasizing the systems failures and the implemented solutions to build trust in the reporting process.