CHPPC Module 14, Section 1: The Daily Rounding Workflow
MODULE 14: BEDSIDE PHARMACIST SAFETY ROUNDS

Section 1: The Daily Rounding Workflow

This section is the operational core of decentralized pharmacy practice. We will move beyond the “why” of bedside rounding and into the “how.” You will learn to build a personal, efficient, and highly effective daily workflow that allows you to maximize your impact on patient safety. We will cover the crucial pre-rounding preparation that sets you up for success, provide a detailed framework for patient selection to focus your efforts, and outline a systematic checklist for your physical review of medications and lines at the bedside. This is the practical, step-by-step guide to transforming yourself from a central pharmacist into a true unit-based clinical practitioner.

1.1 Designing Your Workflow: A Three-Phase Approach

Structuring your day for maximum efficiency and clinical impact.

A successful bedside rounding practice is not about aimlessly wandering the halls. It is a structured, disciplined activity built on a foundation of thorough preparation, systematic execution, and diligent follow-up. By breaking your rounding process into three distinct phases, you can create a predictable and repeatable workflow that ensures you are always prepared, efficient, and effective. This three-phase approach—Prepare, Execute, Follow-Up—will become the daily rhythm of your decentralized practice.

Retail Pharmacist Analogy: The Monthly Controlled Substance Inventory

Performing your monthly or biennial controlled substance inventory is a zero-error, multi-phase process. You don’t just start counting pills. Phase 1 is Preparation: You gather your materials—the inventory logs, the binder of invoices, a calculator, and a partner. You choose a quiet time to ensure you won’t be interrupted. Phase 2 is Execution: You systematically go through the safe, counting every tablet and logging every count, with your partner double-checking your work. Phase 3 is Follow-Up: You don’t just put the binder away. You reconcile the physical count against the perpetual inventory, investigate any discrepancies, and file the signed, dated records in a secure location for a potential DEA audit. It’s a professional, structured workflow from start to finish.

Your daily rounding workflow follows this exact same professional structure. Your preparation is the chart review. Your execution is the physical bedside visit. And your follow-up is the documentation and communication that closes the loop. It’s the same disciplined mindset you already possess, now applied to a clinical setting.

1.1.1 The Three Phases of a Pharmacist’s Daily Rounds

Phase 1: Pre-Rounding Data Collection (The Pharmacist’s Workup)

Time: First 60-90 minutes of your shift. Location: Central pharmacy or a quiet computer station. This is the most critical phase. The quality of your preparation dictates the quality of your interventions. This is where you use the EHR to identify your target patients and perform a deep dive into their profiles to identify potential medication-related issues before you ever set foot on the unit.

Phase 2: Execution (The Bedside Safety Review)

Time: Mid-morning (typically 09:00-11:00). Location: On the patient care unit. This is the “boots on the ground” phase. You will physically go to the patient rooms, interact with the nurses, and perform a systematic safety check of the medications, lines, and pumps. This is where you gather the real-world data that the EHR cannot provide.

Phase 3: Follow-Up, Documentation, and Communication

Time: Late morning/Early afternoon. Location: Back at a computer station or during team rounds. This is where you synthesize the data from your chart review and your bedside review to take action. You will write clinical notes, contact providers with recommendations, and communicate your findings to the rest of the healthcare team, ensuring that your interventions are implemented and the loop is closed.

1.2 Phase 1 Deep Dive: Patient Selection and Pre-Rounding Workup

How to find the needles in the haystack: Focusing your impact.

You cannot and should not attempt to see every patient on a 40-bed unit every single day. The key to a sustainable and high-impact rounding practice is prioritization. Your pre-rounding workup is a process of clinical triage, using the data in the EHR to identify the patients who are at the highest risk for medication-related problems and who will benefit most from your direct attention. Your goal is to generate a focused, manageable list of 5-10 target patients for the day.

1.2.1 Patient Selection Strategies: A Tiered Approach

Most EHR systems allow you to create customized patient lists based on specific criteria. You can work with your informatics team to build a “Pharmacist High-Risk” list that automatically flags patients for you. This list should be built on a tiered system of risk factors.

Priority Tier Patient Characteristics Rationale
Tier 1: Highest Priority (Must-See Daily) – Patients in the ICU
– New admissions (within 24h) on >10 medications
– Patients on high-alert continuous infusions (heparin, insulin, vasopressors)
– Patients receiving TPN
– Patients on multiple antibiotics for sepsis
– Patients with acute, significant renal or hepatic failure		 These patients are clinically dynamic, on the most dangerous medications, and have the highest potential for rapid deterioration. Errors in this population have the most severe consequences.
Tier 2: Medium Priority (See 2-3 times/week) – Patients with polypharmacy (>15 home meds)
– Patients on narrow therapeutic index drugs (warfarin, digoxin, anti-epileptics)
– Patients with a history of significant adverse drug reactions
– Patients with multiple comorbidities (e.g., HF, COPD, CKD)
– Patients receiving complex pain management regimens		 These patients are at high risk for drug interactions, toxicities, and non-optimized therapy. They require regular, but not necessarily daily, pharmacist oversight.
Tier 3: Lower Priority (Review via EHR daily, see as needed) – Clinically stable patients on routine medications
– Patients awaiting placement or discharge on a stable regimen
– Patients admitted for minor procedures or observation		 While still deserving of a daily profile review from the central pharmacy, these patients are less likely to require a physical bedside visit unless a specific issue is flagged (e.g., a critical lab value).

1.2.2 The Pre-Rounding Pharmacist’s Workup

Once you have your prioritized list of 5-10 patients, you must perform a systematic chart review for each one. This is not a superficial glance. This is a deep dive, identical to the workup you would perform before presenting a patient on clinical rounds. Your goal is to create a worksheet (either on paper or in a digital document) for each patient, summarizing the key data and identifying potential issues to investigate at the bedside.

A Pharmacist’s Pre-Rounding Worksheet Template

For each target patient, your worksheet should have these key sections:

  • Patient Demographics: Name, MRN, Room #, Age, Weight, Allergies.
  • Primary Diagnosis & Active Problems: Why are they here? What are the main issues being treated?
  • Key Labs/Vitals: Focus on trends. Is the creatinine climbing? Is the potassium dropping? Are they still febrile? Note any critical values from the last 24 hours.
  • High-Alert Medications: List all active high-alert meds (insulin, anticoagulants, narcotics, etc.). Note the current dose, rate, and any recent changes.
  • Antimicrobial Review: List all antibiotics. What day of therapy is it? Are cultures back? Is de-escalation possible?
  • Prophylaxis Check: Is VTE and SUP prophylaxis ordered and appropriate?
  • “Questions to Investigate at Bedside”: This is the most important section. Based on your chart review, what do you need to physically see or ask?
    • “Patient is on a continuous heparin drip. Need to verify the pump settings and check for signs of bleeding.”
    • “Patient has 4 IV piggybacks due at 10:00. Need to check their IV access and Y-site compatibility.”
    • “Patient’s home med list includes two different inhalers. Need to assess their inhaler technique.”
    • “New order for vancomycin. Patient has a listed penicillin allergy. Need to clarify the nature of the reaction with the patient.”

1.3 Phase 2 Deep Dive: The Bedside Safety Review Checklist

Your systematic “five-point inspection” at the point of care.

Armed with your pre-rounding worksheet, you are now ready to proceed to the unit. The goal of this phase is to use your physical presence to gather data that is unavailable in the EHR and to intervene on safety issues in real time. Your first stop should be a brief check-in with the charge nurse to announce your presence and ask if there are any immediate pharmacy-related issues (“fire drills”) that need your attention. From there, you will proceed to your target patients’ rooms. Your review at each bedside should be a systematic, repeatable “five-point inspection.”

The Bedside Safety Checklist: Your Five-Point Inspection

This checklist is your script for every room you enter. It ensures your review is comprehensive and efficient.

  1. Point 1: The IV Lines (“Trace the Lines”)

    This is often the highest-yield check. Start at the IV bag and physically trace the tubing with your eyes and fingers all the way to the patient’s skin. You are looking for:

    • Correct Labeling: Does every line have a label identifying the drug and the date/time it was hung? A “naked” line is a serious error.
    • Kinks and Obstructions: Is the tubing kinked under the patient or caught in the bedrail, obstructing flow?
    • Signs of Phlebitis/Infiltration: Look at the IV insertion site. Is there redness, swelling, or tenderness? Ask the patient if the site is painful.
    • Compatibility Confirmation: If multiple infusions are Y-sited together, does this match the compatibility you confirmed during your pre-round?
  2. Point 2: The IV Pump (“Verify the Program”)

    Look directly at the screen of the infusion pump. Do not trust the EHR to be 100% accurate. The pump is the final source of truth for what the patient is actually receiving.

    • Drug Library Compliance: Is the pump running in the “Guardrails” or smart pump mode? If it’s running in basic mode, a critical safety feature is being bypassed.
    • Program Match: Does the drug, concentration, and rate displayed on the pump screen exactly match the active order in the EHR and the label on the bag?
    • Active Alerts: Are there any active alerts or alarms on the screen (e.g., “Occlusion,” “Air in Line,” “Guardrail Override”) that need to be addressed?
  3. Point 3: The Medications (“Scan the Environment”)

    Scan the patient’s bedside table, drawers, and windowsill. You are looking for any medications that shouldn’t be there.

    • Patient’s Own Medications (POMs): Has the patient brought in their own medications from home? If so, these need to be identified by a pharmacist and either sent home or stored securely by the pharmacy per hospital policy. Unidentified POMs at the bedside are a major source of error.
    • Expired or Discontinued Meds: Is there a discontinued IV bag still hanging? Is a multi-dose vial (like an insulin pen) being used that is past its 28-day expiration after opening?
  4. Point 4: The Patient (“Observe and Inquire”)

    Briefly and respectfully observe the patient. You are not performing a physical exam, but you are using your clinical observation skills.

    • Level of Sedation: If the patient is on opioids or sedatives, are they appropriately awake, or are they overly somnolent?
    • Visible Signs of ADRs: Do you notice any new rashes, bruising, or edema that could be drug-related?
    • Direct Questions: This is your chance to clarify issues from your workup. “Good morning, Mr. Smith. I’m Chris, the pharmacist. I see you have an allergy to penicillin listed. Can you tell me what kind of reaction you had?” or “I see you have two inhalers here. Could you show me how you use this one?”
  5. Point 5: The Nurse (“Collaborate and Close the Loop”)

    Find the patient’s primary nurse. This is your most important collaborative partner. Briefly share your findings and ask for their input.

    • Share Findings: “Hi Jane, I was just in to see Mr. Smith in room 2. I noticed his heparin drip is running in basic mode, not in the drug library. Can we quickly reprogram that to make sure the guardrails are active?”
    • Ask for Input: “My workup shows his pain seems to be poorly controlled on the current regimen. How has he been for you? Has he been asking for his PRN frequently?”
    • Offer Help: “Is there anything you need from pharmacy? Any missing meds or questions I can help with while I’m here?” This simple offer builds immense goodwill.