CHPPC Section 19.6: Guided Practice Set
Part 5: Data Entry & EHR Mastery (New Track)

Module 19: Meditech (Expanse) — Order Entry & Verification

19.6 Guided Practice Set: The Digital Proving Ground

Applying your comprehensive knowledge in a series of guided, high-fidelity clinical simulations to forge true “digital muscle memory.”

Welcome to the capstone of your Meditech training. Theory has laid the groundwork, and deep dives have provided the blueprints, but it is only through deliberate, focused practice that true mastery is achieved. This final section is your clinical proving ground—a series of realistic, high-stakes inpatient scenarios designed to test and solidify every skill you have learned in this module. You will be placed in the digital hot seat, tasked with verifying some of the most complex and error-prone orders in hospital pharmacy. Each case is a comprehensive simulation, complete with a patient profile, a realistic (and flawed) Meditech order, and a guided masterclass walkthrough. The goal is to move beyond simple knowledge and into the fluid, instinctual application of that knowledge—to build the “digital muscle memory” that separates a novice user from an expert clinical guardian. This is where your transformation into a confident, efficient, and exceptionally safe hospital pharmacist is finalized.

19.6.1 Case 1: The Neonatal Gentamicin Dosing Challenge

A 3-day-old premature neonate (Gestational Age: 34 weeks) in the NICU develops a fever and elevated inflammatory markers, concerning for early-onset sepsis. The neonatologist places an order for ampicillin and gentamicin. The gentamicin order appears in your unverified queue.

19.6.1.1 Simulated Meditech Order

VERIFY ORDER: Gentamicin IV
PatientBABYGIRL, DOE
MRN555667788
Patient Weight2.1 kg (from banner)
AllergiesNKDA
Age3 days
SCr0.7 mg/dL
MedicationGentamicin IV
Dose8.4 mg
FrequencyQ24H
Monitoring[NULL]

19.6.1.2 Your Task

Perform a complete clinical verification of this high-risk neonatal order. Identify all potential issues related to the patient’s data, the dosing, the frequency, and the monitoring plan. Formulate your recommendations and determine the necessary actions.

19.6.1.3 Masterclass Walkthrough

Step 1: Uncovering Pitfall #1 – The Weight Discrepancy

As covered in the “Common Pitfalls” section, your first action for any neonatal weight-based dose is to distrust the banner weight. You must find the source of truth.

  • Action: Navigate to the nursing flowsheets in the PCS module.
  • Discovery: You find the official daily scale weight documented at 06:00 this morning was 2.06 kg.
  • Analysis: The banner weight of 2.1 kg is a rounded value. For a neonate, this is an unacceptable level of imprecision. All calculations must be based on the 2.06 kg weight.
  • Dose Recalculation: The provider appears to have used a standard 4 mg/kg dose with the rounded weight (4 mg/kg * 2.1 kg = 8.4 mg). Your more precise calculation is 4 mg/kg * 2.06 kg = 8.24 mg. You will recommend adjusting the dose to 8.2 mg.

The Unforgiving Nature of Neonatal Dosing

In adults, a 2% difference in dose is rarely consequential. In a neonate with immature renal function receiving a nephrotoxic and ototoxic drug, these small differences contribute to cumulative toxicity. Precision is not a preference; it is the standard of care.

Step 2: Identifying Pitfall #2 – The Frequency Error

Neonatal aminoglycoside dosing is not one-size-fits-all. The appropriate dosing interval is highly dependent on two key factors: Post-Menstrual Age (PMA) and Post-Natal Age (PNA). PMA = Gestational Age + Post-Natal Age.

  • Patient’s Data: Gestational Age = 34 weeks. Post-Natal Age = 3 days. PMA = ~34 weeks.
  • Consulting the Dosing Protocol: You open your hospital’s neonatal dosing guidelines (e.g., Neofax or a custom protocol). For a patient with a PMA of 30-34 weeks who is ≤ 7 days old, the standard dosing interval for gentamicin is Q36H, not Q24H.
  • Analysis: The ordered Q24H frequency is too frequent for this premature neonate’s immature kidneys. This dosing interval would lead to drug accumulation and a significantly increased risk of toxicity.
Step 3: Identifying Pitfall #3 – The Missing Monitoring Plan

Therapeutic drug monitoring (TDM) is mandatory for aminoglycosides to ensure efficacy while avoiding toxicity. The order is missing a plan to assess drug levels.

Traditional vs. Extended Interval Monitoring

For traditional (e.g., Q8H) dosing, you would monitor peaks and troughs. For Extended Interval Dosing (like Q36H), the goal is to have a high peak for bacterial killing and a long, drug-free interval to minimize toxicity. Therefore, monitoring focuses on a single random level drawn 6-14 hours post-dose, which is then plotted on a nomogram (like the Hartford nomogram, adapted for neonates) to determine if the frequency is appropriate.

Step 4: Intervention and Documentation
  1. Action: Place the order on hold. You have identified three critical errors that must be corrected.
  2. Communication: This level of intervention requires a direct conversation. You will call the neonatologist.
    Your Conversation Script:
    “Dr. Adams, this is [Your Name], the NICU pharmacist. I’m verifying the gentamicin order for Babygirl Doe. I have a couple of recommendations to optimize the dose for her age and weight.

    First, her precise scale weight from this morning is 2.06 kg, so I’ve calculated the 4 mg/kg dose to be 8.2 mg.

    More importantly, given her PMA of 34 weeks and being only 3 days old, our protocol recommends a Q36H interval to ensure adequate drug clearance, rather than the ordered Q24H.

    I’d also like to add the standard monitoring order for a random gentamicin level 6-14 hours after the first dose. Would you be okay if I make those adjustments?”
  3. Correcting the Order in Meditech: After getting verbal approval, you will:
    • Edit the original order, changing the dose to 8.2 mg and the frequency to Q36H.
    • Add a new, linked order for the random gentamicin level.
    • Enter a detailed comment explaining the changes.
  4. Final Documentation:
    Pharmacist Note (Intervention):
    “Gentamicin order adjusted per neonatal sepsis protocol. Spoke with Dr. Adams. Dose adjusted to 8.2 mg based on precise weight of 2.06 kg. Frequency adjusted to Q36H based on patient’s PMA (~34 wks) and PNA (3 days) to minimize risk of accumulation. Added order for random level to monitor therapy. Verbal order received and entered. [Your Name], PharmD.”

19.6.2 Case 2: The Proactive IV-to-PO Conversion

You are performing daily clinical rounds on the medical floor. You are reviewing the profile of a 58-year-old male who was admitted 3 days ago for a severe cellulitis of his right leg. His active medication list includes “Levofloxacin 750 mg IV DAILY.” You decide to assess his eligibility for conversion to oral therapy.

19.6.2.1 Your Clinical Investigation (Simulated Chart Review)

PATIENT CHART REVIEW: Michael Johnson
PatientJOHNSON, MICHAEL
MRN224466880
Active IV ABXLevofloxacin 750 mg IV DAILY
Diet OrderRegular Diet
Temp (last 24h)Max: 37.5°C
WBC (today)9.2 K/uL (yesterday: 12.8)

— Nursing Notes (Last 12 Hours) —

“Patient ambulating in halls with PT. Reports significant improvement in leg pain and swelling. Eating 100% of meals. No N/V/D noted. IV site clean, dry, intact.”

19.6.2.2 Your Task

Based on your chart review, determine if the patient is an appropriate candidate for conversion from IV to PO levofloxacin. If so, execute this clinical intervention using a simulated Meditech Pharmacy-Driven Panel.

19.6.2.3 Masterclass Walkthrough

Step 1: Systematic Assessment for Conversion Criteria

The IV-to-PO Checklist: Your Mental Model

An expert pharmacist runs through a mental checklist for every IV antibiotic patient, every single day.

  • Overall Clinical Improvement? Yes, nursing notes confirm significant improvement.
  • Afebrile? Yes, max temp is 37.5°C.
  • Trending-Down WBC? Yes, WBC has normalized.
  • Functioning GI Tract? Yes, tolerating a regular diet with no N/V/D.
  • Oral Equivalent Available? Yes, levofloxacin has excellent (~100%) oral bioavailability, making it a perfect candidate for a 1:1 conversion.

Conclusion: The patient is a textbook perfect candidate for conversion.

Step 2: Executing the Meditech “IV to PO Conversion Panel”

This is a proactive, pharmacist-initiated intervention. You are not waiting for a provider’s order; you are generating the orders yourself based on a pre-approved hospital protocol.

  1. Launch the Panel: In the Meditech PHA module, with Mr. Johnson as the active patient, you search for and launch the “IV to PO Antimicrobial Conversion Panel.”
  2. Populate the Panel’s Fields: The panel is an interactive form that guides you through the process.

    — IV to PO Conversion Panel —

    1. Select IV to Discontinue: [You click here and select the active “Levofloxacin 750 mg IV DAILY” order from a list].

    2. Select PO to Initiate: [You click here, and the system, knowing the original drug was levofloxacin, automatically suggests the 1:1 oral equivalent].

        New Order: Levofloxacin 750 mg Tablet PO DAILY.

    3. Set Duration: [You review the original admission date and set the duration to complete a 7-day total course of therapy].

    4. Reason for Conversion (Required): [You select from a dropdown list: “Meets Clinical Criteria for IV to PO Conversion”].

  3. Review and Sign: The panel bundles the discontinuation order and the new oral order into a single package. You do a final review to ensure everything is correct and then electronically sign the panel with your credentials.
Step 3: Communication and Documentation

Even though the protocol allows you to act independently, clear communication is a professional courtesy and a safety net.

Pharmacist Note (Intervention):
“Patient reviewed for antimicrobial stewardship. Meets all clinical criteria for conversion to oral therapy (afebrile, WBC normalized, tolerating PO diet). Initiated IV to PO conversion panel per pharmacy protocol. Discontinued IV levofloxacin and initiated PO levofloxacin 750 mg daily to complete a 7-day course. This change has been made to reduce the risk of line-related complications, decrease cost, and facilitate discharge planning. No provider notification required per protocol.”