CHPPC Module 22, Section 5.3: The Pharmacist’s Role: The Pre-Procedure Safety Officer
MODULE 22: THE HOSPITAL ECOSYSTEM

Section 5.3: The Pharmacist’s Role: The Pre-Procedure Safety Officer

Solidifying your identity as an indispensable leader in perioperative safety by mastering the art of proactive intervention, cognitive verification, and effective communication.

SECTION 5.3

The Pharmacist’s Role: The Pre-Procedure Safety Officer

From passive checker to proactive guardian.

Introduction: Redefining Your Professional Identity

This final section of our masterclass is the most important. It is not about learning new facts, but about synthesizing everything you have learned into a new professional identity: the Pre-Procedure Safety Officer. This is a role that transcends the traditional boundaries of pharmacy. A “checker” passively verifies that an order is written correctly. A “Safety Officer,” by contrast, is a proactive, cognitive force who anticipates risk, identifies system-level vulnerabilities, and intervenes *before* an error can occur. The “Why” of this section is to instill this mindset. It is to move you from a state of “Is this order correct?” to a more profound state of “Is this plan safe?” This requires a combination of deep clinical knowledge, situational awareness, and the courage to communicate effectively. It is the culmination of your journey from community expert to indispensable hospital clinician.

Retail Pharmacist Analogy: From DUR Alert Resolver to Air Traffic Controller

For most of your career, you’ve been an expert DUR Alert Resolver. Your computer flags a potential interaction or a dose that’s too high. This is a reactive process. You see the alert, you analyze the problem, and you resolve it. It is a critical, but fundamentally reactive, safety function.

The Pre-Procedure Safety Officer is an Air Traffic Controller for medications. You are not waiting for the collision alarm to go off. You are looking at the entire airspace (the patient’s EMR). You see one “plane” (the patient’s chronic warfarin) on a flight path to the “airport” (the OR). You see another “plane” (a dose of enoxaparin for VTE prophylaxis) taking off too close to the landing time. You see a “thunderstorm” (the patient’s renal dysfunction) that requires rerouting flight plans. You are proactively communicating with all the pilots (surgeon, anesthesia, nursing) to adjust speeds, altitudes, and headings to ensure that every plane lands safely, without ever triggering a single collision alert. This proactive, systems-level view of safety is the essence of your new role.

Mastery 1: The Art of the Proactive Intervention

Seeing the problem before it becomes an order.

The most effective safety officers don’t just catch errors; they prevent the conditions that allow errors to occur. In perioperative care, this means engaging with the patient’s case long before the final pre-surgical order set is even written. This is the practice of “case finding” and proactive consultation.

Developing Your “High-Risk Radar”: Daily Case Finding

Every day, you should be electronically scanning the list of patients scheduled for procedures in the next 24-48 hours. You are hunting for specific, high-risk medication scenarios that you know will require a detailed plan. Your goal is to identify these patients and begin formulating a recommendation before the surgeon or anesthesiologist is scrambling to write orders the morning of the procedure.

Your High-Risk Patient Watchlist

When scanning the OR schedule, you should immediately flag patients with any of the following characteristics for a proactive chart review:

  • Complex Anticoagulation: Any patient on warfarin, a DOAC, or therapeutic-dose LMWH. Does their record have a clear plan for holding and/or bridging?
  • Complex Pain Management: Any patient on chronic high-dose opioids, a fentanyl patch, buprenorphine, or methadone. Their baseline opioid requirements will be high and they are at risk for withdrawal.
  • Brittle Diabetes: Any patient on an insulin pump or with a history of frequent DKA or severe hypoglycemia.
  • Severe Renal or Hepatic Dysfunction: These patients will require dose adjustments for nearly everything.
  • Significant Polypharmacy: Any patient on >15 home medications is at high risk for interactions, omissions, and errors.
  • History of Malignant Hyperthermia: This is a rare but life-threatening reaction to certain anesthetics. You must ensure the OR is aware and prepared.

Case Study: Proactive Management of a Patient on Buprenorphine

Scenario: It’s Tuesday. While reviewing the OR schedule for Wednesday, you see a 45-year-old male scheduled for a knee replacement. On his home medication list, you see buprenorphine/naloxone (Suboxone) 8mg/2mg SL BID for opioid use disorder.

Your “High-Risk Radar” goes off. You know that buprenorphine is a partial mu-opioid agonist with a very high binding affinity. This means it can block the effect of full agonists (like morphine, hydromorphone) that will be needed to control his acute post-operative pain. If not managed correctly, this patient’s pain will be impossible to control.

Your Proactive Intervention (Day Before Surgery):

You don’t wait for an order. You page the surgeon and the anesthesia team with a clear, concise recommendation:

“This is the pharmacist regarding your patient scheduled for a TKA tomorrow, who is on chronic buprenorphine therapy. To ensure adequate post-operative pain control, current guidelines recommend a ‘continue and supplement’ strategy. I recommend the following plan:

  1. Continue the patient’s home dose of buprenorphine/naloxone 8/2 mg BID throughout the perioperative period to prevent withdrawal.
  2. For post-operative pain, plan to use high doses of full agonist opioids (e.g., a hydromorphone PCA) to overcome the partial blockade. Expect his requirements to be higher than an opioid-naïve patient.
  3. Consider a multimodal approach with regional anesthesia (e.g., a nerve block), scheduled acetaminophen, and NSAIDs to minimize opioid requirements.

Can we get these orders entered now to ensure a smooth plan for tomorrow?”

By intervening a day early, you have transformed a potential post-operative pain crisis into a well-managed, evidence-based plan.

Mastery 2: The Final Verification – A Cognitive Checklist

Thinking beyond the check boxes.

When you perform your final verification of the pre-surgical order set, you are doing more than just confirming the data points we discussed in Section 5.2. You are running a final cognitive simulation of the patient’s journey. You are asking not just “Is it correct?” but “Does it make sense?” This is the difference between a technician and a clinician. This is your “stop the line” moment, your last chance to catch a subtle but critical flaw in the plan.

The Pre-Procedure “What-If” Cognitive Checklist

After you’ve verified all the individual orders, take a step back and ask yourself these global, critical thinking questions:

  • The “Big Picture” Question: “Does this entire medication plan—the holds, the continues, the new orders—tell a coherent and safe story for this specific patient undergoing this specific procedure?”
  • The “Worst-Case Scenario” Question: “What is the single most likely medication-related adverse event to happen to this patient, and is there a clear plan to prevent or mitigate it?” (e.g., For a patient on insulin, is there a clear hypoglycemia protocol? For a patient on anticoagulants, is the reversal agent readily available?).
  • The “Contradiction” Question: “Are there any orders that contradict each other?” (e.g., An order to hold all oral intake, but also an order for an oral antibiotic? An order for an epidural and an order for therapeutic enoxaparin?).
  • The “Missing Piece” Question: “Is there anything obviously missing?” (e.g., No VTE prophylaxis ordered for a high-risk procedure? No bowel regimen for a patient who will be on high-dose opioids? No stress-dose steroids for a patient on chronic prednisone?).

Common Red Flags and Your “Stop the Line” Intervention

You See This Red Flag… Your Cognitive Alarm Bells Should Ring… Your Immediate “Stop the Line” Intervention
An order for Vancomycin 1.5g IV for a patient scheduled for surgery in 45 minutes. “This is impossible. A standard 1.5g vancomycin infusion takes 90-120 minutes. The infusion will not be complete by the time of incision, making the prophylaxis ineffective and non-compliant with guidelines.” Call the OR/Anesthesia immediately. “The ordered vancomycin cannot be administered within the required 120-minute window before incision. The alternative for a beta-lactam allergic patient is clindamycin, which can be infused in 30 minutes. Recommend switching to Clindamycin 900mg IV.”
A pre-op order set for a patient with ESRD on hemodialysis. The orders include enoxaparin 40mg daily and morphine PCA post-op. “This patient has no renal clearance. Both enoxaparin and the active metabolites of morphine will accumulate to toxic levels. This plan is unsafe.” Page the surgeon/team. “This patient has ESRD. Enoxaparin is contraindicated. VTE prophylaxis should be with unfractionated heparin 5000 units SUBCUT Q8H. Additionally, morphine is unsafe. Post-op pain should be managed with an agent that does not have active renal metabolites, such as hydromorphone or fentanyl.”
An order to continue a patient’s home SGLT2 inhibitor (e.g., empagliflozin) the morning of surgery. “This violates the 3-day hold rule. This patient is at high risk for developing euglycemic DKA post-operatively due to the stress of surgery and being NPO.” Contact the ordering provider. “Per FDA recommendations and institutional guidelines to prevent euglycemic DKA, SGLT2 inhibitors must be held for at least 3 days prior to surgery. This morning’s dose must be held. Please confirm you agree to hold the empagliflozin.”

Mastery 3: Communication – Closing the Loop

How you say it is as important as what you say.

Finding a potential error is only half the battle. If you cannot communicate your finding effectively and professionally, your intervention will fail. As a Pre-Procedure Safety Officer, you must be a master of clear, concise, and collaborative communication. This means presenting your findings in a structured way, providing evidence-based recommendations, and ensuring that your intervention is not just heard, but acted upon.

The SBAR Framework: Your Blueprint for Effective Communication

When you need to call a physician about a medication safety concern, don’t just “wing it.” Use the SBAR framework to structure your thoughts and ensure you deliver a clear, actionable message.

Using SBAR for a Perioperative Intervention
  • S – Situation: State who you are, which patient you are calling about, and the immediate problem.
    “Dr. Smith, this is John the pharmacist calling about your patient Jane Doe, who is scheduled for a hip replacement at 10 AM. I have a concern about her pre-operative antibiotic order.”
  • B – Background: Provide the essential context.
    “She has a documented penicillin allergy in her chart, described as ‘hives and swelling.’ The pre-operative order is for cefazolin.”
  • A – Assessment: State your professional assessment of the situation.
    “Given her history of a true IgE-mediated reaction to penicillin, there is a risk of cross-reactivity with cefazolin. Using it is a potential safety risk.”
  • R – Recommendation: Provide a clear, evidence-based, and actionable recommendation.
    “The guideline-recommended alternative for patients with a beta-lactam allergy for this procedure is Vancomycin 1.5g IV. Since her surgery is in two hours, we need to get this infusion started as soon as possible to meet the 120-minute pre-incision window. Can I get a verbal order to switch the cefazolin to vancomycin?”

“Closing the Loop” and Documenting Your Impact

An intervention isn’t complete until you know it has been acted upon. This is called “closing the loop.”

  • Read-Back: After receiving a verbal order, read it back to the prescriber to confirm accuracy. “Okay, so I am entering a new order for Vancomycin 1.5 grams IV x1 dose now. Is that correct?”
  • Confirmation of Action: Ensure the order is not only entered, but that the nurse is aware of it and is acting on it. A quick call or message to the patient’s nurse is essential. “Hi, just a heads-up, I spoke with Dr. Smith and we are switching the pre-op antibiotic to vancomycin. The order is in. Pharmacy will send it up shortly.”
  • Document, Document, Document: Your final step is to document your clinical intervention in the patient’s chart. This is critical for communication, legal liability, and demonstrating the value of pharmacy services. A good intervention note is concise and follows the SBAR format.

Navigating Disagreements and Escalating Concerns

Occasionally, a prescriber may disagree with your recommendation. It is vital to handle this professionally and to have a clear understanding of the “chain of command” if you believe a serious safety issue remains unresolved.

The Chain of Command: Your Safety Net

If you cannot reach an agreement with the primary provider and you have a good-faith belief that the current plan puts the patient at significant risk, you have a professional obligation to escalate your concern. The typical chain of command is:

  1. Initial Provider (e.g., the surgical resident).
  2. Attending Physician (e.g., the attending surgeon or anesthesiologist).
  3. Your Pharmacy Supervisor or Clinical Manager.
  4. The Chief of the Service (e.g., Chief of Surgery).
  5. The Hospital’s Patient Safety Officer or Chief Medical Officer.

Escalating a concern is not a sign of conflict; it is a sign of a healthy safety culture. Always frame your escalation professionally: “I have a safety concern that I have been unable to resolve with the primary team, and I would like to request your assistance.”