Module 20: Cerner (Millennium/PharmNet) — Order Entry & Verification

20.6.1.3 Masterclass Walkthrough

Step 1: Dose Verification for Obesity

• Weight-Based Dosing: Cefazolin dosing for SSI prophylaxis is weight-dependent to ensure adequate tissue concentrations.
• Protocol Check: You consult your hospital’s SSI prophylaxis guidelines. They state:
  • Patients < 120 kg: Cefazolin 2g IV.
  • Patients ≥ 120 kg: Cefazolin 3g IV.
• Analysis: The patient’s weight is 85 kg. The ordered 2g dose is correct.

Step 2: Identifying Pitfall #1 – The Critical Timing Error

Your Intervention: Best practice is to aim for the middle of the window. You should modify the order to be given slightly earlier to ensure a buffer.

Step 3: Identifying Pitfall #2 – The Missing Re-Dosing Order

This is a high-level clinical pitfall that requires you to think beyond the initial dose. You must consider the duration of the procedure.

Step 4: Intervention and Documentation

1. Action: You will modify the original order for timing and add a new, conditional order for re-dosing.
2. Communication: This is a complex intervention that requires clear communication with both the surgeon and the anesthesiologist who will be administering the intra-operative dose.
   Your Communication (Note to Provider(s)):
   “Re: Pre-op cefazolin for James Miller. Two adjustments made to ensure optimal SSI prophylaxis per SCIP guidelines:
   
   1. The administration time for the initial 2g dose has been adjusted to 06:45 to ensure the infusion is complete prior to the 07:30 incision time.
   
   2. A second, conditional order for ‘Cefazolin 2g IVPB x 1 dose’ has been added with the indication ‘For intra-operative re-dosing if surgical time exceeds 4 hours.’ This will appear on the Anesthesia MAR for administration.
   
   Please review and co-sign. Thank you.”
3. Executing in Cerner:
   • You will “Modify” the original order and change the scheduled time to 06:45.
   • You will “Add” a new order for Cefazolin 2g IVPB, but in the frequency/details, you will specify it is a conditional, one-time order with the specific indication for intra-op re-dosing.
   • You will then “Propose” these changes, sending them to the provider for their electronic co-signature.

20.6.2.3 Masterclass Walkthrough

Step 1: Identifying Pitfall #1 – The “Order Comment” Trap

Step 2: Identifying Pitfall #2 – The Unnecessary Non-Standard Concentration

As covered in previous modules, deviating from the hospital’s standard concentration for a high-alert drip is a major safety risk. The provider has requested a “double strength” drip (8mg/250mL) when the likely hospital standard is 4mg/250mL. Your first question must be: “Is there a compelling clinical reason for this?” For a 100 kg patient, a standard drip is almost always sufficient. The provider is likely doing this out of habit, not clinical necessity, and in doing so, is sacrificing the smart pump safety net.

Step 3: Intervention – Rebuilding the Order Correctly

This order cannot be “modified.” It is fundamentally flawed and must be discontinued and reordered correctly. Your goal is to convert the provider’s free-text intent into a fully structured, standardized order.

1. Action: Place the original order on hold or request discontinuation. You will propose a new order.
2. Communication: Contact the ICU provider.
   Your Conversation Script:
   “Dr. Evans, this is the pharmacist. I’m calling about the norepinephrine order for Mr. Davis. I see the comment requesting a double-strength concentration. To ensure we can use the smart pump’s safety guardrails, would it be okay to switch this to our hospital-standard 4mg/250mL concentration? We can still achieve the same target MAP without any issue. I can build the order with the standard titration parameters for you to sign.”
3. Building the New Order in Cerner: After getting approval, you will create a new order from scratch, using all the structured fields.

   – Select Medication: Norepinephrine 4mg/250mL D5W IV Infusion (The Standard Product)

   – Rate/Dose: Start at 0.05 mcg/kg/min (Cerner will calculate the mL/hr rate)

   – Titration Parameters: Titrate by 0.01-0.02 mcg/kg/min every 5 minutes.

   – Titration Goal: To maintain MAP between 65-75 mmHg.

   – Max Rate: 0.5 mcg/kg/min (or per hospital protocol).

4. Final Documentation:
   Pharmacist Note (Intervention):
   “Original free-text order for non-standard norepinephrine D/C’d. Spoke with Dr. Evans, who agreed to switch to hospital-standard concentration (4mg/250mL) to enable use of smart pump safety guardrails. New order entered with standard initiation and titration parameters. Ready for verification.”