CHPPC Module 17, Section 3: Common Inpatient Order Types
Part 5: Data Entry & EHR Mastery

Module 17: Hospital Order Entry Fundamentals

Welcome to the command center of inpatient care. Your experience processing thousands of prescriptions with speed and accuracy is one of your greatest assets. In this module, we will translate that foundational skill into the complex, dynamic world of hospital order entry. We’ll demystify the Electronic Health Record (EHR) and show you that beneath any specific software lies a universal logic—a logic you are already well-equipped to master.

17.3 Common Inpatient Order Types: A Practical Masterclass

Developing fluency in the most frequent and high-risk order verification scenarios.

Having mastered the individual fields within the Order Composer, we now elevate our focus to the complete picture: the order itself. Inpatient orders are rarely simple, one-line commands. They are often complex, multi-faceted therapeutic strategies. Your role is to evolve from a data field checker to a clinical strategy evaluator. This section provides a deep, practical dive into the most common and highest-risk categories of orders you will encounter daily. We will dissect each type, linking the technical verification steps to the underlying clinical reasoning.

17.3.1 Intermittent IV Antibiotics (IVPBs)

IV Piggybacks are the bedrock of inpatient antimicrobial therapy. While seemingly straightforward, their safe verification requires a multi-layered clinical assessment that goes far beyond simply checking the drug and dose.

Retail Pharmacist Analogy: The “Supercharged” Z-Pak

In your retail practice, verifying a Z-Pak (azithromycin) is a routine task. You check for allergies, and drug interactions, and ensure the directions are clear. You dispense the entire course of therapy at once, entrusting the patient to complete it correctly.

In the hospital, verifying an order for IV Zosyn (piperacillin/tazobactam) is like managing that Z-Pak on a dose-by-dose, hour-by-hour basis for a critically ill patient. You are not just dispensing a box; you are actively managing the patient’s renal function to adjust the dose, deciding on the optimal infusion time to maximize efficacy, and planning the transition to an oral equivalent. You are the architect of the entire therapeutic course, not just the gatekeeper of the initial dispense.

17.3.1.1 Your Verification Checklist for IVPBs

  • The “Right Drug, Right Dose” Check: This is your foundation. Is the antibiotic appropriate for the suspected infection (e.g., does it cover Pseudomonas for a hospital-acquired pneumonia)? Is the dose correct for the patient’s weight and the indication?
  • The Renal Function Assessment: This is a non-negotiable step for almost all antibiotics. You must calculate the patient’s creatinine clearance (CrCl) using the Cockcroft-Gault equation and ensure the ordered dose and frequency are appropriate. Many EHRs do this automatically, but you must be able to spot-check and verify its accuracy.
  • Extended Infusion vs. Traditional Dosing: For beta-lactams like Zosyn and meropenem, extended infusions (e.g., infusing over 3-4 hours instead of 30 minutes) are increasingly common to optimize time above the MIC. You must verify that the rate and duration are set correctly to achieve this goal.
  • Therapeutic Drug Monitoring (TDM): For drugs with narrow therapeutic windows, such as vancomycin and aminoglycosides, your role is central. You’ll verify initial doses, recommend timing for drug levels (troughs or peak/trough pairs), and use those levels to calculate patient-specific pharmacokinetic parameters to optimize future doses.

Vancomycin Dosing: From Troughs to AUC/MIC

The standard of care for vancomycin monitoring is shifting from targeting simple trough concentrations (e.g., 15-20 mg/L) to targeting an Area Under the Curve to Minimum Inhibitory Concentration ratio (AUC/MIC) of 400-600. This is a more accurate predictor of efficacy and is associated with a lower risk of nephrotoxicity. Your role as a pharmacist is to lead this charge:

  1. Use approved software (or manual calculations) to determine an initial, patient-specific dose aimed at achieving the target AUC/MIC.
  2. Order pharmacokinetic labs (e.g., two levels drawn post-dose) at steady state.
  3. Use these levels to calculate the patient’s actual AUC/MIC and adjust the dose or frequency as needed.

This is a prime example of how the hospital pharmacist’s role has evolved into a highly clinical, data-driven practice.

17.3.2 Continuous IV Infusions (“Drips”)

These are the highest-alert medications you will manage, providing constant, powerful pharmacologic effects that can change a patient’s physiology in minutes. Your verification process for these orders must be flawless, as errors can have immediate and severe consequences.

Retail Pharmacist Analogy: The Garden Hose vs. The Water Glass

In retail, most medications you dispense are like giving someone a glass of water (a discrete dose) at set intervals. Its effect is gradual, and a single missed dose is rarely catastrophic.

A continuous infusion is like a garden hose connected directly to a delicate plant. The flow is constant and powerful. Your job is to verify the “spigot” (the IV pump) is programmed perfectly—not just the starting flow, but also the rules for turning it up or down (titration) and the absolute maximum flow allowed. A small, incorrect twist of that spigot can either wither the plant or flood it entirely within minutes.

17.3.2.1 Masterclass by Drip Type:

Infusion Type Your Critical Verification Points Common Errors to Catch
Vasopressors (Norepinephrine, Vasopressin) Confirm standard concentration. Ensure a max rate is specified. Verify the clinical goal (e.g., MAP > 65). Check for central line access. Missing max rate; ambiguous titration parameters (e.g., “titrate to effect”); ordered for a patient with only peripheral IV access.
Insulin Verify 1 unit/mL concentration. Ensure order is linked to a blood glucose monitoring protocol (e.g., hourly checks). Confirm the starting rate and titration algorithm are appropriate for the indication (e.g., DKA vs. hyperkalemia). Non-standard concentration; failure to order frequent glucose checks; using the wrong protocol for the patient’s condition.
Heparin Verify weight-based bolus and initial rate calculations are correct per the approved nomogram. Check baseline platelets to screen for HIT. Confirm appropriate monitoring (aPTT or anti-Xa) is ordered. Incorrect patient weight used for calculation; manual math errors; failure to order follow-up labs, leading to sub- or supra-therapeutic anticoagulation.
Sedatives (Propofol, Dexmedetomidine) Confirm concentration. Ensure a clear goal is defined (e.g., “Maintain RASS -1 to 0”). Verify a max rate is present. Note propofol’s lipid content for TPN calorie calculations and its risk for hypertriglyceridemia. Missing sedation goal; no max rate; prolonged high-dose propofol infusions without monitoring triglycerides.

17.3.3 Patient-Controlled Analgesia (PCA) & Epidurals

These specialized infusions for pain management put powerful controlled substances under the partial control of the patient or are delivered near the spinal cord. They require an exceptionally rigorous verification process due to the high risk of respiratory depression and other severe adverse effects.

The Ultimate High-Stakes Order

Verification of PCA and epidural orders is a zero-error-tolerance task. It almost always requires an independent double-check by a second pharmacist before the medication is dispensed. You are verifying not just a drug, but a complex, programmable delivery system with multiple potential points of failure.

17.3.3.1 Deconstructing the PCA Order

A complete PCA order is a multi-part command that defines the rules of the infusion pump. You must verify each component individually and ensure they work together logically and safely.

  • Loading Dose (Optional): An initial, larger dose given by the nurse to achieve rapid pain control.
  • Demand Dose: The amount of drug the patient receives each time they press the button.
  • Lockout Interval: The “refractory period” after a demand dose during which the pump will not deliver more medication, even if the patient presses the button. This is a key safety feature to prevent overdose. A typical lockout is 6-10 minutes.
  • Basal Rate (Optional): A low-dose continuous infusion that runs in the background, independent of the patient’s button presses. This is a major source of risk, especially in opioid-naïve patients, and its use must be carefully justified.
  • 1-hr and 4-hr Limits: The maximum cumulative dose the patient can receive in a given period. The pump is programmed not to exceed this limit.

17.3.3.2 Epidural Orders: The Pharmacist’s Role

Your verification of epidural orders focuses on drug selection and formulation. The primary check is to ensure that any medication intended for epidural administration is 100% PRESERVATIVE-FREE. Preservatives like benzyl alcohol can be neurotoxic if administered into the epidural space. You are the final, critical backstop to prevent a catastrophic formulation error.

17.3.4 Total Parenteral Nutrition (TPN)

TPN orders are arguably the most complex orders you will ever verify, representing a complete, custom-compounded intravenous nutrition source. Verification is a daily, multi-step process involving chemistry, clinical assessment, and pharmaceutical calculations.

Retail Pharmacist Analogy: The Ultimate Custom Compound

Imagine a patient asks you to compound a custom multivitamin smoothie. In retail, you might mix some protein powder, vitamins, and minerals. TPN is this concept magnified a thousandfold. You are compounding a sterile, life-sustaining liquid from 20+ individual ingredients. You must calculate the exact amount of dextrose for calories, amino acids for protein synthesis, electrolytes to correct lab abnormalities, and trace elements for enzymatic function. Most importantly, you must ensure they don’t all precipitate into a solid chunk in the bag. It is the pinnacle of pharmacist-led custom compounding.

17.3.4.1 The Daily TPN Verification Workflow

  1. Review Morning Labs: Your first step is to check the patient’s latest Basic Metabolic Panel (BMP), magnesium, and phosphate levels.
  2. Assess Patient Status: Is the patient fluid-overloaded? Are they diabetic, requiring less dextrose? Are their triglycerides high, requiring a reduction in lipids?
  3. Verify Macronutrients: Check the ordered amounts of dextrose (carbohydrates), amino acids (protein), and IV fat emulsion (lipids) for clinical appropriateness.
  4. Verify Micronutrients: Adjust the electrolyte additives (sodium, potassium, calcium, phosphate, magnesium) based on the morning’s lab results to correct deficiencies or avoid toxicity.
  5. The Calcium-Phosphate Solubility Check: This is the most critical chemical check. Using specialized software or manual curves, you must confirm that the concentrations of calcium gluconate and potassium/sodium phosphate will not exceed the solubility limit and precipitate. This is a potentially fatal incompatibility that only the pharmacist can reliably prevent.
  6. Confirm Filter Type: A 1.2-micron filter is required for 3-in-1 (TNA) formulations containing lipids, while a 0.22-micron filter is used for 2-in-1 (dextrose/amino acids) formulations.