CHPPC Module 27, Section 3: Common Night Crises
MODULE 27: AFTER-HOURS, NIGHTS & ON-CALL REALITIES

Section 27.3: Common Night Crises: Missing Meds, Tube Down, Pump Alarms, Lab Delays

Your Tactical Field Guide for Troubleshooting the Inevitable After-Hours Fires with Poise and Precision.

SECTION 27.3

Common Night Crises

Transforming panic into procedure with a systematic playbook for the night shift’s most frequent challenges.

27.3.1 The “Why”: From Clinical Expert to Master Troubleshooter

During the day shift, your role is primarily that of a clinical expert, surrounded by a robust operational infrastructure. If a medication is missing, a specialized technician investigates. If a pump is alarming, a clinical engineering team is available. If a tube is clogged, a procedure team can be consulted. After hours, this infrastructure vanishes. Your role necessarily expands beyond the purely clinical; you become the de facto operational troubleshooter for all things medication-related. A nurse’s first and often only call will be to you, the lone pharmacist on watch.

These “night crises” are rarely complex clinical conundrums. They are almost always logistical or mechanical failures that have the potential to escalate into clinical emergencies if not handled correctly. A missing antibiotic can lead to a delay in treating sepsis. A clogged feeding tube can lead to missed doses of a critical anti-epileptic. An unresolved pump alarm for a vasoactive drip can lead to life-threatening hemodynamic instability. Your ability to systematically diagnose, troubleshoot, and solve these operational problems is a core competency of the after-hours pharmacist.

This section is not about pharmacology; it’s about procedure. We will provide you with a series of battle-tested, step-by-step playbooks for the most common crises you will face. The goal is to give you a pre-defined algorithm to follow in a stressful situation, allowing you to move from a state of reactive panic to one of proactive, procedural calm. Mastering these playbooks will build immense confidence in your own abilities and earn you the trust and gratitude of the night shift nursing team.

27.3.2 The Analogy: The Ship’s Engineer on the Mid-Watch

A Deep Dive into the Analogy

During the day, the hospital functions like a Fully Crewed Cruise Ship. If an issue arises, there is a specialized department for everything. An electrical problem? Call the electricians. A plumbing issue? Call the plumbers. You, the clinical pharmacist, are an officer focused on a specific, high-level aspect of the ship’s operation.

At 03:00 in the middle of the ocean, you are the Lone Engineer on the Mid-Watch. The captain (the on-call attending) and the rest of the specialized crew are asleep. The ship is quiet, but the engines are still running, and the sea is unpredictable. Suddenly, a cacophony of alarms blares in the engine room. It’s not one clear problem; it’s a series of cascading alerts. A fuel pump is alarming, a pressure valve is reading in the red, and a strange vibration is coming from the main turbine.

  • You don’t panic. You don’t immediately call and wake the captain.
  • You grab your diagnostic toolkit and your procedural manuals. You work the problem.
  • You start with the most critical alarm, systematically troubleshooting the issue. You check the fuel line (the medication order), you inspect the valve (the pump), and you analyze the sensor data (the lab results).
  • You solve the small fires yourself. You discover the fuel pump alarm was just a faulty sensor you could reset. You find the clogged tube was a simple obstruction you could clear.
  • Only when you encounter a problem you cannot solve—a true, catastrophic engine failure—do you use your radio to wake the captain with a clear, concise report of the problem, what you’ve already done, and what you need from them.

This section is your engineering toolkit and your procedural manual. It will teach you how to be that calm, systematic troubleshooter in the engine room when the alarms start ringing.

Masterclass Part 1: Crisis Playbook #1 — The Missing Medication

This is, without a doubt, the most common call you will receive. It can range from a routine stool softener to a life-saving STAT antibiotic. Your approach must be systematic, efficient, and communicative.

The Systematic Search Algorithm: A Step-by-Step Investigation

When the call comes in, resist the urge to immediately re-dispense. A duplicate dose can be as dangerous as a missed one. Follow this algorithm every time.

  1. Step 1: Triage the Urgency. Your first question to the nurse should be: “How urgently is this medication needed?” A STAT antibiotic for a septic patient requires a different level of speed than a scheduled vitamin. This dictates the pace of your investigation.
  2. Step 2: Verify the Order. Before you do anything else, pull up the patient’s profile. Is there actually a correct, active, and verified order for the medication in question? Is it for the right patient? It’s surprisingly common for a nurse to be looking for a med that was already discontinued.
  3. Step 3: Check the Digital Trail. Follow the path of the dose in your systems.
    • MAR/EHR: Does it show the dose as administered? Due? Overdue?
    • Pharmacy System: Does your system show the dose as packed, checked, and tubed/delivered? Note the time.
    • ADC Log: Was the medication pulled from the Automated Dispensing Cabinet? Was it pulled under this patient’s name or another patient’s by mistake? Was it returned?
  4. Step 4: The Physical Search (Remote Guidance). Ask the nurse to perform a quick physical search of the most common “lost” spots while you are checking the digital trail.
    • “Can you please double-check the patient’s medication drawer/bin?”
    • “Could it be in the unit refrigerator?”
    • “Can you quickly scan the ADC return bin?”
  5. Step 5: The Escalation Point. If you cannot locate the medication within a clinically appropriate timeframe (e.g., 5-10 minutes for an urgent med), stop searching. It is safer to re-dispense the dose and continue investigating later than to cause a significant clinical delay. Communicate this clearly: “Sarah, I can’t locate the first dose, so to be safe I am sending a new one right now. I will continue to investigate what happened to the original.”

Masterclass Part 2: Crisis Playbook #2 — The Clogged Feeding Tube

A clogged nasogastric (NG), orogastric (OG), or gastrostomy (PEG/G-tube) tube at 02:00 is a major problem. It can prevent the administration of nutrition and, more critically, essential medications like anti-epileptics or anti-rejection drugs. The nurse will often call you, the pharmacist, as the resident expert on medication-related tube issues.

The Pharmacist’s De-Clogging Protocol

When a nurse calls about a clog they have been unable to clear with a simple water flush, you can guide them through the evidence-based best practice. This often involves a pharmacist-prepared “cocktail.”

Step 1: The Warm Water Flush (To Be Performed by Nursing First)

The first-line approach is to use a gentle push-pull motion with a 30-60 mL syringe filled with warm water. This resolves most minor clogs.

Step 2: The Pancreatic Enzyme “Cocktail” (The Pharmacist’s Solution)

If the water flush fails, the most effective approach is an enzymatic de-clogger. Acidic solutions like cranberry juice or sodas are not recommended as they can actually worsen protein-based clogs.

The Recipe for Success

The standard-of-care enzymatic cocktail is prepared as follows. You may need to create a mini-policy or procedure for this at your institution if one doesn’t exist.

  • Ingredients: One non-enteric-coated pancreatic enzyme tablet (e.g., Viokace®, or a crushed Creon® capsule’s contents) AND one crushed 325 mg sodium bicarbonate tablet.
  • Preparation: Crush both tablets to a fine powder. Mix the powder with 5-10 mL of warm water in an oral syringe.
  • Administration: Instill the mixture into the clogged tube. Clamp the tube.
  • Dwell Time: Allow the mixture to dwell in the tube for at least 30-60 minutes.
  • Follow-Up: After the dwell time, attempt to flush the tube again with warm water. This process can be repeated if necessary.
Prevention: The “Do Not Crush” List is Your Shield

The vast majority of clogs are caused by the improper administration of medications that should not be crushed. Part of your role is to educate nurses and prescribers on safe practices. Be the gatekeeper for this. If you see an order for a “Do Not Crush” medication for a tube-fed patient, you must intervene.

Do Not Crush CategoryRationaleCommon Examples
Enteric-Coated (EC) Crushing destroys the coating that protects the drug from stomach acid or protects the stomach from the drug. Aspirin EC, Pantoprazole EC, Dulcolax®
Extended/Sustained/Controlled Release (ER, SR, CR, XL, LA) Crushing causes “dose dumping”—the entire day’s worth of medication is released at once, leading to toxicity. This is extremely dangerous. Metoprolol Succinate XL, OxyContin®, Verapamil SR, Nifedipine ER
Hazardous Drugs Crushing can aerosolize the drug, posing a risk to the healthcare provider administering it. Warfarin, Finasteride, most Chemotherapy agents
Sublingual/Buccal Designed for absorption through the oral mucosa, not in the GI tract. Nitroglycerin SL, Fentora®

Masterclass Part 3: Crisis Playbook #3 — The Alarming Smart Pump

Modern IV infusions are run on “smart pumps” with sophisticated drug libraries that provide a critical layer of safety. However, when these pumps alarm at night, the nurse’s first call is often to pharmacy, the “drug experts.” Your role is to be a calm, remote troubleshooter.

The Pump Alarm Triage Algorithm

When a nurse calls about a pump alarm, your first step is to gather data. Use this systematic approach.

  1. Identify the Alarm: Ask the nurse, “What is the exact message the pump is giving you?” This is your most important diagnostic clue.
  2. Triage “Line” vs. “Library”: The vast majority of alarms are one of two types:
    • Line Alarms (Occlusion, Air-in-Line): This is a nursing/physical issue. Guide the nurse with basic troubleshooting questions: “Have you checked for any kinks in the tubing?” “Have you tried flushing the patient’s IV line to ensure it’s patent?”
    • Library Alarms (Dose Out of Range, Concentration Mismatch): This is a pharmacy issue. This alarm means the ordered dose/rate is outside the pre-programmed safety limits in the pump’s drug library. This is a critical safety warning that you must investigate.
  3. Investigate Library Alarms: If it’s a library alarm, you must immediately verify the order. Is the ordered rate/dose correct? If the order is correct but is outside the pump’s “soft” or “hard” limits, a clinical decision must be made. This may require you to wake the on-call provider to get approval for a clinical override.

Masterclass Part 4: Crisis Playbook #4 — The Delayed or Missing Lab

Your ability to make safe dosing decisions for drugs like vancomycin or heparin is entirely dependent on timely lab results. At night, with a skeleton lab staff, delays are common. This creates a dangerous “data vacuum” where you must make a clinical decision without all the information.

The “Hold vs. Give” Framework for a Delayed Vancomycin Trough

Scenario: It’s 01:00. A patient’s next vancomycin dose is due at 02:00. The trough level was drawn at 01:00, but the lab calls and says their machine is down for maintenance and the result will be delayed for 2-3 hours. Do you tell the nurse to give the dose or hold it?

Your Decision-Making Matrix:
Factor to Consider Leans Toward GIVING the Dose Leans Toward HOLDING the Dose
Renal Function Trend Creatinine is stable or improving. Creatinine is rising (AKI).
Previous Levels Previous troughs have been at the low end or below the goal range. Previous troughs have been at the high end or above the goal range.
Patient’s Clinical Status Patient is still septic, febrile, with a high WBC count. The risk of under-dosing is high. Patient is clinically improving. The risk of one delayed dose is low.

Your Action & Documentation: You weigh these factors to make the safest possible decision. For example: “Patient’s creatinine has been stable and previous trough was 12. Risk of under-dosing in this septic patient outweighs the risk of a single potentially high dose. Recommended nurse to give the 02:00 dose. Will ensure day shift follows up on the delayed trough level at 06:00 to make any necessary adjustments.” This documentation protects the patient and demonstrates your professional judgment.