CHPPC Module 11, Section 1: Communicating with Nurses
MODULE 11: PROFESSIONAL PRACTICE & COMMUNICATION

Section 1: Communicating with Nurses

Welcome to one of the most important transitional modules in this entire program. Your success, satisfaction, and safety impact as a hospital pharmacist will be determined not just by your clinical knowledge, but by your ability to forge a strong, collaborative, and respectful partnership with the nursing staff. In retail, you are the final checkpoint for the patient. In the hospital, you and the nurse are the two final, essential checkpoints for medication safety. This section will translate your expert communication skills from a patient-facing role to a peer-to-peer professional relationship that is the bedrock of inpatient care.

1.1 The Art of Order Clarification: Beyond the Prescription

Translating your verification expertise into the complex world of CPOE and inpatient orders.

In retail pharmacy, your role as a gatekeeper of prescription accuracy is paramount. You scrutinize every detail: the drug, the dose, the sig, the prescriber’s DEA number, the date. This skill is not just relevant in the hospital; it is the absolute foundation upon which your new role is built. However, the nature of the “prescription” changes dramatically. You will move from interpreting a single, discrete order to interrogating a complex, interconnected web of orders within a patient’s electronic health record (EHR). Your primary communication partner in this process is no longer the prescriber’s office staff, but the frontline nurse who will administer the medication.

Retail Pharmacist Analogy: The “Clindamycin 150mg #120” Prescription

A new patient brings in a prescription for clindamycin 150mg with a quantity of 120 and no directions. Your pharmacist’s intuition immediately fires off a series of questions. Is this for dental prophylaxis? If so, the quantity is far too high. Is it for a skin infection? The duration is unusual. Is it for long-term bacterial vaginosis suppression? Maybe, but you need context. You don’t just fill it. You pause, pick up the phone, and call the prescriber’s office to clarify the indication, intended directions, and duration. You are protecting the patient from potential harm or ineffective therapy based on an ambiguous order.

In the hospital, this same scenario plays out a dozen times a day, but the ambiguity is embedded within the EHR. You might see a new order for “Vancomycin 1g IV Q12H” for a patient with no documented infection and perfect renal function. Your role is identical to the clindamycin scenario: you must pause and investigate. But instead of calling the prescriber’s office, your first and most valuable collaborator is often the patient’s nurse. They have the most up-to-date clinical context that the EHR may not yet reflect.

1.1.1 From Paper Scripts to CPOE: A New Landscape of Ambiguity

Computerized Prescriber Order Entry (CPOE) has eliminated issues with illegible handwriting, but it has introduced a new class of potential errors. Understanding these will guide your clarification questions.

  • The “Click-and-Pick” Error: In a dropdown menu of medications, a provider might accidentally click “clonidine” instead of “clonazepam” or select the wrong concentration of an infusion.
  • Order Set Incompleteness: Providers often use pre-built “order sets” for common conditions (e.g., “Pneumonia Admission Order Set”). These sets may contain default doses or frequencies that are inappropriate for a specific patient’s weight, age, or renal function. The provider may have overlooked the need to customize it.
  • Therapeutic Duplication: A common issue where a patient may have an active order for an IV PPI from the ED, and then the admitting physician orders a scheduled oral PPI without discontinuing the first one.
  • Timing and Administration Conflicts: An order might be written for a PO medication for a patient who is now NPO (nothing by mouth) for a procedure, or an IV push medication for a patient who only has a fragile peripheral IV line that can’t tolerate it.

1.1.2 The SBAR Framework: Your Blueprint for Effective Communication

When you identify an issue requiring clarification, you cannot simply call the nursing station and ask, “What’s up with this vanco order?” Your communication must be structured, professional, and efficient. The SBAR framework is the universal language of healthcare communication and your most valuable tool.

Component Description Example Dialogue with a Nurse
Situation A concise statement of the problem. What are you calling about? “Hi Sarah, this is Chris from pharmacy calling about your patient in room 412, Mr. John Smith. I have a new order for vancomycin that I have a question on.”
Background Brief, relevant clinical context. What information is critical to understanding the problem? “I see he was admitted from the ED for a presumed cellulitis. His creatinine on admission was 0.8, and he doesn’t seem to have any other active infectious signs or symptoms documented.”
Assessment Your professional assessment of the situation. What do you think the issue is? “The vancomycin order is for a standard 1g Q12H dose, but without a clear indication or baseline cultures, I’m hesitant to verify it. I want to make sure we’re treating the right thing and avoiding unnecessary nephrotoxicity.”
Recommendation Your proposed solution or what you need from the other person. “Could you confirm with the patient if they’ve discussed a new antibiotic with the team? Or do you know if the provider is planning to get wound cultures before we start? If not, I’d like to recommend we page the provider to clarify the indication before I send the first dose.”

Clinical Pearl: “Reading the Room” Before You Call

Before picking up the phone, do your homework. A nurse’s primary frustration with pharmacy calls is when they are asked for information that is readily available in the EHR. Take 60 seconds to check:

  • Recent Vitals: Is the patient febrile? Tachycardic? Hypotensive?
  • Lab Trends: Is the White Blood Cell count trending up? Is the creatinine stable?
  • Provider Notes: Skim the last progress note. Did the provider mention starting an antibiotic for a specific reason?
  • MAR: Is there another antibiotic already being given?

When you call with this information already in hand, you transform the conversation from an interrogation into a collaborative problem-solving session. You are showing the nurse you respect their time and are working as a true partner.

1.1.3 Phrasing is Everything: Building a Collaborative Tone

The way you phrase your questions can make the difference between being seen as a helpful colleague and a bureaucratic obstacle. Your goal is to convey curiosity and a shared commitment to patient safety, not to challenge the nurse or the provider.

Instead of This (Confrontational) Try This (Collaborative) Why It Works
“Why was this ordered? There’s no indication.” “Hi, I’m reviewing a new order for drug X and wanted to touch base to make sure I have the most up-to-date picture. Can you help me understand the team’s thinking for starting it?” Positions the nurse as a knowledgeable partner who can provide missing context. It assumes good intent.
“This dose is wrong for the patient’s renal function.” “I was looking at Mr. Smith’s new enoxaparin order and noticed his creatinine has bumped to 2.1 this morning. I’d like to suggest we recommend a renal dose adjustment to the provider. What are your thoughts?” Presents your clinical finding and includes the nurse in the proposed solution, fostering teamwork.
“You can’t give this PO, the patient is NPO.” “I see there’s a new order for oral metoprolol, but I also see the NPO order for his procedure later today. Do you know if the team wants to give this with a sip of water, or should I recommend we ask for an IV equivalent?” Acknowledges the conflict and presents options, empowering the nurse and showing you’re thinking ahead to solve the problem, not just identify it.

1.2 Navigating Technology-Driven Conflicts: BCMA & Smart Pumps

Your new role as a real-time troubleshooter for medication administration technology.

In retail, your pharmacy management system generates alerts for drug interactions, high doses, or duplicate therapies. You resolve these before the medication ever reaches the patient. In the hospital, this same principle extends to the point of administration through two key technologies: Barcode Medication Administration (BCMA) and smart infusion pumps. When a nurse scans a medication and receives an alert, you are often their first call. Your ability to quickly and accurately troubleshoot these alerts is crucial for maintaining both safety and nursing workflow efficiency.

1.2.1 BCMA: The Five Rights in Digital Form

BCMA is designed to digitally enforce the “Five Rights” of medication administration: Right Patient, Right Drug, Right Dose, Right Route, and Right Time. The nurse scans their own badge, the patient’s wristband, and the medication’s barcode. The system then compares these three inputs against the active medication order in the EHR. A mismatch in any category generates an alert or a hard stop. This is where you come in.

Deep Dive: Understanding Common BCMA Scanning Errors

When a nurse calls you because “the drug won’t scan,” it’s rarely a simple technical glitch. It is a signal of a potential process error that requires your detective skills. Your goal is to figure out why the system is rejecting the scan. The most common reasons fall into a few key categories:

  • Wrong Patient: The nurse may have grabbed medication for the patient in bed A but is trying to administer it to the patient in bed B. BCMA is the final, life-saving catch for this error.
  • Wrong Drug/Dose: This is the most common reason for a pharmacy call.
    • Product Mismatch: The order is for “Lisinopril 10mg Tablet” but the nurse is scanning a “Lisinopril 20mg Tablet” they plan to split. The system sees a different NDC and rejects it.
    • Concentration Mismatch: The order is for a “Fentanyl 50 mcg/mL” vial, but the pharmacy dispensed a “Fentanyl 250 mcg/5mL” vial. Same dose, different product in the system’s eyes.
    • Formulation Mismatch: The order is for “Metoprolol Succinate XL” but the ADC dispensed “Metoprolol Tartrate”. This is a critical clinical error caught by the system.
  • Wrong Time: The nurse is attempting to administer a medication too far outside the scheduled window (e.g., trying to give a 10 AM dose at 1 PM).
  • Discontinued or Inactive Order: The provider may have discontinued the medication, but a dose was still on the nursing unit. The scan is correctly rejected because there is no active order to match it to.

Your guiding principle: A BCMA alert is a symptom, not the disease. Your job is to diagnose the underlying discrepancy in the medication use process, which often originates in the pharmacy’s dispensing step or the provider’s ordering step.

1.2.2 Troubleshooting BCMA Alerts: A Pharmacist’s Protocol

When you receive a call about a scanning failure, follow a systematic approach. Your pharmacy’s order entry screen is your primary investigation tool.

  1. Identify the Key Players: Get the patient’s name/MRN and the name of the medication and dose in question.
  2. Confirm the Active Order: Immediately pull up the patient’s profile. Is the order active? Is it for the exact drug, dose, and route the nurse is describing? Verbally confirm this with the nurse. “Okay, I see an active order for Lisinopril 10mg tablet due at 0900. Is that what you have?”
  3. Verify the Dispensed Product: This is the critical step. In your pharmacy system, you can see the exact NDC of the product that was verified and dispensed for that patient’s order. Ask the nurse to read you the NDC from the package in their hand.
    • If the NDCs match, it could be a technical issue (e.g., wrinkled barcode) or a timing issue.
    • If the NDCs do not match, you have found the source of the error. The wrong product is at the bedside.
  4. Resolve the Discrepancy:
    • Pharmacy Error: If pharmacy dispensed the wrong NDC (e.g., 20mg instead of 10mg), apologize, take ownership, and immediately tube or deliver the correct medication. Instruct the nurse to return the incorrect product.
    • Nursing Error: If the nurse grabbed the wrong medication from the ADC or a fridge, guide them to the correct one. “It looks like you grabbed the 20mg tablet. The patient’s 10mg dose should be in bin 34 of the ADC.”
    • Order/Build Issue: If the correct drug was dispensed but the order was built in the EHR with the wrong barcode information, this requires an informatics fix. In the short term, you may need to follow your hospital’s downtime or override procedures to allow the nurse to administer the medication safely while you work on a long-term fix.

1.2.3 Smart Pumps: Guardrails for IV Infusions

Smart infusion pumps contain a “drug library” that you, the pharmacist, help build and maintain. This library contains pre-set concentrations and dose limits (soft and hard) for high-risk infusions. When a nurse programs the pump, they select the drug from the library, and the pump’s “guardrails” help prevent catastrophic programming errors (e.g., entering 100 mg/hr instead of 10 mg/hr).

However, alerts still occur, and they often require your clinical judgment to resolve. When a nurse calls about a pump alert, it’s usually one of two types:

  • Soft Alert: “Dose is above recommended limit. Are you sure you want to proceed?” This is a warning that the programmed rate is outside the usual range but can be overridden.
  • Hard Alert: “DOSE IS ABOVE HARD LIMIT. CANNOT PROCEED.” This is a hard stop that cannot be overridden and indicates a potentially fatal dose has been programmed.

1.2.4 Resolving Smart Pump Alerts: A Clinical Conversation

Unlike BCMA alerts, which are often logistical, pump alerts are almost always clinical. Resolving them requires a collaborative assessment of the patient’s immediate needs.

Scenario & Alert Your Investigative Questions for the Nurse Collaborative Resolution
Heparin Infusion: Nurse calls saying they are trying to program a rate of 2500 units/hr for a DVT protocol, but they are getting a soft alert because the library limit is 1800 units/hr. “Thanks for calling to double-check. What is the patient’s weight? What does the most recent aPTT look like? Is the patient showing any signs of active bleeding?” “Okay, the patient is 120kg and the aPTT is still sub-therapeutic at 45. The protocol does call for this higher rate for patients over 100kg. This is clinically appropriate. Thank you for verifying; you can override the soft alert and proceed. Please document our conversation.”
Norepinephrine Infusion: Nurse calls from the ICU. “I’m trying to titrate my norepinephrine up to 40 mcg/min for profound septic shock, but I’m getting a hard limit alert at 30 mcg/min.” “Understood. What’s the patient’s current blood pressure and heart rate? Are they on any other vasopressors right now? Has the provider seen the patient recently?” “Okay, the patient is crashing and this titration is necessary. The hard limit is a safety feature, but in this case, it’s preventing needed therapy. We need a new order from the provider to use a higher concentration ‘septic shock’ profile in the pump, or they need to come to the bedside. Let me get the provider on the phone with us right now to resolve this.”
PCA Pump: A nurse calls from the surgical floor. “The provider ordered a hydromorphone PCA with a 0.2mg bolus, but my only library option is ‘Dilaudid PCA 1mg/mL’, and it won’t let me program a dose that high.” “I see the problem. The order is for a dose, but the pump needs a concentration. Can you confirm what concentration bag you have from pharmacy? Is it a 1mg/mL bag or a 0.2mg/mL bag?” “Ah, it looks like the provider ordered the bolus dose as ‘0.2mg’ but they meant to order the concentration as ‘0.2mg/mL’. I will call the provider to get a corrected order to read ‘Hydromorphone PCA 0.2mg/mL concentration’. Please do not run the pump until we have that corrected order. I will send up the correct bag once it’s fixed.”

1.3 The Pharmacist as a Drug Information Resource

Delivering concise, actionable, and evidence-based answers under pressure.

In retail, your drug information skills are primarily directed at patient counseling—explaining side effects, administration techniques, and the importance of adherence in an accessible, empathetic manner. In the hospital, you are a clinical consultant to your nursing colleagues. They will call you with questions that are more technical, urgent, and directly related to the immediate act of administering a medication. Your ability to provide a fast, accurate, and confident answer is a key factor in building trust and establishing yourself as an invaluable member of the care team.

Retail Pharmacist Analogy: The “Can I Crush This?” Patient Question

A patient’s caregiver calls you. “My dad has trouble swallowing pills. The doctor prescribed Toprol XL. Can I crush it for him?” You immediately know this is a critical question. You don’t just say “no.” You explain why: “That’s an excellent question. Toprol XL is a long-acting tablet, and crushing it would cause all the medication to be released at once, which could dangerously lower his blood pressure.” Then, you immediately pivot to a solution: “Let me call the doctor for you. There’s an immediate-release version of the same medication, metoprolol tartrate, that can be crushed, or we could ask about switching to a different medication that comes in a liquid.”

This exact scenario happens daily in the hospital, but the caller is a nurse. They might call and ask, “My patient in 602 has a new PEG tube, and I have an order for potassium chloride 20mEq extended-release tablet. Can I crush this?” Your response process is identical: provide the direct answer (no), explain the clinical reasoning (risk of massive, irritating potassium bolus), and immediately offer a viable, pharmacy-driven solution (propose ordering potassium chloride oral solution).

1.3.1 The Taxonomy of Nursing Drug Information Questions

Nursing questions typically fall into a few key categories. Anticipating these will help you prepare and know which resources to have at your fingertips.

Category of Question Common Examples Your Go-To Resource Key to a Good Answer
Administration/Formulation “Can I crush this tablet?”
“Can I give this IV push? Over how long?”
“Is this medication compatible with Normal Saline?”		 Lexicomp (IV Compatibility/Trissel’s), Package Insert, Clinical Pharmacology Actionable & Specific. Not just “yes,” but “Yes, you can crush it and mix with applesauce.” Not just “slowly,” but “Give IV push over at least 2 minutes.”
Adverse Effects “My patient just got their first dose of lisinopril and is coughing. Could it be the medication?”
“I just gave IV vancomycin and my patient is turning red. What should I do?”		 Micromedex, Lexicomp, UpToDate Triage & Action. “Yes, that’s a known side effect. Is the patient in any respiratory distress? For the vanco, that sounds like Red Man Syndrome. You should stop the infusion and I’ll call the provider to recommend pre-medication with diphenhydramine.”
Dosing & Drips “What’s the standard concentration for a heparin drip?”
“My patient’s potassium is 2.8. How many mEq can I give peripherally?”		 Institutional Protocols/Guidelines, Lexicomp Safety & Policy. “Our standard heparin concentration is 25,000 units in 250mL D5W. For peripheral potassium, our policy limit is 10 mEq/hr to prevent phlebitis.”
Stability & Storage “I just reconstituted this Zosyn. How long is it good for at room temperature?”
“Does this albumin need to be refrigerated?”		 Package Insert, Lexicomp (IV Compatibility/Trissel’s) Clear & Unambiguous. “Reconstituted Zosyn is stable for 4 hours at room temp or 24 hours refrigerated. The albumin can be stored at room temperature.”

1.3.2 The “30-Second Rule”: Structuring Your Answer for a Busy Nurse

A nurse who calls you for drug information is likely standing at the patient’s bedside or in the medication room, multi-tasking and facing interruptions. They need the answer, and they need it now. Your response should be structured to deliver the most critical information upfront.

  1. Give the Bottom Line First: Start with a direct “yes” or “no” or the specific number they need.
  2. Provide the “Why” Briefly: Give a one-sentence clinical pearl or safety reason. This builds their knowledge and reinforces your role as an educator.
  3. Offer a Solution or Next Step: If there’s an issue, immediately pivot to what should be done about it.
  4. Confirm Understanding: End with a simple, “Does that make sense?” to ensure the information was received correctly.

Example Application of the “30-Second Rule”

Nurse’s Question: “Hi, this is Jane on 5 North. I have an order for IV phenytoin for my patient in 501. Can I mix this in his running bag of D5W?”

Your Structured Answer:

“Hi Jane. (1) No, absolutely do not mix phenytoin with D5W. (2) It will precipitate immediately in dextrose. You must use Normal Saline only and it requires a filter. (3) I can send you a specific phenytoin administration kit that includes the filter tubing. I’ll also double-check that the patient has a good, large-bore IV for the infusion to prevent extravasation. (4) Does that make sense?“

This entire exchange takes less than 30 seconds. It directly prevents a serious medication error, explains the reasoning, provides a complete solution, and confirms understanding. This is the gold standard for pharmacy-nursing drug information interactions.

1.3.3 When You Don’t Know the Answer

It is perfectly acceptable not to know the answer to every obscure question immediately. Honesty and a commitment to follow-up are far more valuable than a guess. A nurse will trust you more if you are transparent.

The Wrong Way: “Umm, I think that’s probably okay…”

The Right Way: “That is an excellent and unusual question. I am not 100% certain off the top of my head, and I do not want to give you the wrong information. Let me look that up right now in Trissel’s and call you back in two minutes. What’s the best number to reach you at?”

This response demonstrates professionalism, a commitment to safety, and respect for the nurse’s query. And critically, you must follow through and call them back within the promised timeframe.