Section 2: EHR & ADC Downtime Procedures

When the technology fails, we revert to a robust, pre-planned paper-based system. Every nursing unit and the pharmacy itself will have a “Downtime Kit,” often a large, brightly colored binder or box. This kit contains all the physical forms, logs, and resources needed to run the medication-use process manually. As a pharmacist, you must be intimately familiar with the contents of this kit, as it becomes your new operating system.

2.2.1 Anatomy of a Downtime Kit

Let’s dissect the contents of a typical pharmacy downtime kit. This is your arsenal for maintaining order.

Component	Description	Pharmacist’s Role & Focus
Downtime Order Forms	Multi-part, carbon-copy prescription forms. The physician writes an order, the top copy is sent to the pharmacy, and a copy stays on the chart.	This is your new source of truth for orders. You must be an expert in scrutinizing these for completeness (drug, dose, route, frequency, patient name, MD signature). Illegible handwriting becomes a major safety risk.
Paper Medication Administration Records (MARs)	Blank MAR templates. Nurses will manually transcribe all active medications onto these sheets for each patient and use them to document administration times.	You will use these MARs to reconstruct a patient’s medication profile. You must work with nurses to ensure these are accurate and are updated with every new order.
Communication Logs	Spiral notebooks or log sheets to manually document every phone call, clarification, and intervention.	This is your legal record. You must meticulously document the “who, what, when, where, why” of every conversation, as there will be no electronic record.
Pre-Printed Labels	Sheets of blank or pre-formatted labels for IV bags and other dispenses.	You will have to manually write or type all label information. The risk of error is high. A second pharmacist check is critical.
Core Drug Information Resources	Physical copies of key references: The hospital formulary, IV compatibility charts (Trissel’s), dosing guidelines for high-risk drugs.	You lose your electronic references. These physical books (or downloaded offline versions) become your only source for clinical decision support.
Calculators & Forms	Basic calculators, conversion charts, and any forms needed for pharmacokinetics or other specialized services.	You lose all your integrated calculators. You must revert to performing calculations manually.

During an EHR downtime, the pharmacy transforms from a component of the medication-use system into its central nervous system. Every piece of information must flow through you. Your ability to create manual systems, communicate clearly, and lead your team is paramount. The following is a breakdown of your core responsibilities.

2.3.1 Workflow 1: Order Verification & Profile Reconstruction

The flow of new orders will shift from CPOE to a constant stream of paper forms, phone calls, and runners appearing at the pharmacy window.

1. Triage: You must immediately triage incoming orders: STAT vs. Routine. STAT orders get immediate attention.
2. Verification: You must scrutinize the paper order with heightened vigilance. Is it legible? Is it complete? Does it have a valid signature? You must be ruthless in rejecting incomplete or ambiguous orders. Call the provider for clarification and document the call in your log.
3. Profile Reconstruction: This is the most difficult cognitive task. For every order, you must try to reconstruct the patient’s profile to perform a DUR. Your sources are now analog:
   • The patient’s paper MAR (if available and up-to-date).
   • Asking the nurse or provider: “What other medications is this patient on?”
   • The patient’s physical chart, if it can be located.
4. Documentation: Once verified, the order is stamped with the date and time. One copy of the form is kept for pharmacy records, and a runner is dispatched to take another copy back to the floor to be added to the patient’s paper chart and MAR.

2.3.2 Workflow 2: Communication Command Center

With the EHR chat and notification systems gone, the pharmacy phone becomes the single most important communication tool in the hospital. You must manage this influx of information with military precision.

• Designate a “Communicator”: One pharmacist should be assigned the sole role of answering the phone. This prevents other staff from being constantly interrupted.
• The Communication Log is Sacred: Every single piece of clinically relevant information must be logged. “14:35 – Dr. Smith called for patient John Doe. Clarified Zosyn dose is 3.375g Q8H, not Q6H. – C. Pharmacist.” This log will be essential for back-entry and any post-downtime analysis.
• Proactive “Broadcasts”: Use runners and frequent calls to the charge nurses to proactively push out information. “This is pharmacy. Just an update, the EHR is still down. We are prioritizing all STAT and first-dose antibiotics. Please continue to send all orders via the downtime forms.”

If the EHR is the brain, the network of Automated Dispensing Cabinets (ADCs) is the backbone of medication distribution. When the network connection to the ADCs is lost, they can no longer receive new orders or verify patient information. This requires a shift to a manual override process that is faster for the nurse but carries an immense risk, especially for controlled substances. Your role becomes that of a remote security officer and a post-event forensic accountant.

2.4.1 The Override Process: Balancing Access and Control

Most ADCs have a “critical override” or “downtime” function. This allows a licensed nurse to access medications without a current, verified order in the system. To do this, they typically have to acknowledge a series of warnings and document the reason for the override. During a downtime, this becomes the primary method for retrieving urgent medications.

Your Role: While you cannot control this process from the pharmacy, you are the expert who must guide it. You will be in constant communication with the charge nurses, reminding them of the policy: overrides are for urgent/STAT medications only. Routine medications should be sent from the central pharmacy. You must remind them of the critical importance of documenting every single override on the patient’s paper MAR.

When the announcement is finally made—”The EHR system is now back online”—the crisis is not over. In many ways, the most tedious and error-prone work is just beginning. The hospital now has two separate and conflicting realities: the paper world that existed during the downtime, and the now-active electronic world which is completely unaware of everything that has happened. The process of reconciling these two worlds is known as “back-entry,” and it is a massive, all-hands-on-deck undertaking that is often supervised by the pharmacy.

2.5.1 The Monumental Task of Back-Entry

Every single medication event that occurred on paper must now be entered into the EHR to create a complete and legal medical record. This includes:

• Every new physician’s order written on a downtime form.
• Every medication administration documented on a paper MAR.
• Every dose dispensed from the central pharmacy or removed from an ADC on override.

Your Role as Supervisor and Verifier: This task is often shared between physicians, nurses, and pharmacists. You will be responsible for overseeing the pharmacy-related back-entry. You must ensure that every paper order you verified is now correctly entered into the CPOE system. You will then need to perform a “post-downtime reconciliation,” comparing the newly entered electronic orders against the paper MARs to ensure nothing was missed. This is effectively a hospital-wide medication reconciliation and can take many hours.