CHPPC Module 3, Section 2: Common Order Types & Clinical Checks
MODULE 3: THE HEART OF THE JOB

Section 2: Common Order Types & Clinical Checks

Now that you understand the fundamental anatomy of an order, we will apply that knowledge to the most common categories of medications you will verify. This section moves from theory to practice, providing you with the specific clinical checklists and thought processes required to safely manage everything from a simple IV antibiotic to a complex, life-sustaining continuous infusion.

Part 1: Intermittent IVs

The Workhorse of Hospital Pharmacy

Intermittent intravenous infusions, often called “IV piggybacks” (IVPB), are the bread and butter of your daily verification queue. These are medications given at scheduled intervals over a short duration. While antibiotics are the most common example, this category also includes electrolyte replacements, certain diuretics, and many other medications. Their safe verification requires a multi-layered clinical assessment that combines microbiology, pharmacokinetics, and patient-specific parameters.

Retail Pharmacist Analogy: A Timed Sprinkler System

Think of verifying an intermittent IV like setting up a sophisticated, automated garden sprinkler. Your job is to program it perfectly once: you set the amount of water (the dose), the frequency (e.g., every 8 hours), and the duration (e.g., run for 30 minutes). Once programmed, you trust the system to execute the plan automatically. Your expertise is in the initial setup, ensuring all parameters are perfect for the specific needs of the garden (the patient).

The Pharmacist’s Verification Checklist for an IV Antibiotic

When an order like “Cefepime 2 g IV q8h” appears, your mental checklist should immediately activate:

  • 1. Indication Check: Why is this patient on this antibiotic? I need to find a diagnosis in the chart (e.g., “Hospital-Acquired Pneumonia,” “Febrile Neutropenia”) that justifies the use of a broad-spectrum, anti-pseudomonal agent like cefepime.
  • 2. Dose & Renal Function Check: What is the patient’s calculated CrCl? Cefepime requires significant dose reduction for renal impairment to prevent neurotoxicity. Is 2g q8h the correct dose for this patient’s kidney function and the severity of their infection? I must independently verify this.
  • 3. Spectrum of Activity Check: Does this antibiotic cover the likely or known pathogens? I will check the patient’s microbiology results. If their blood cultures are growing an organism resistant to cefepime, I must intervene and recommend a more appropriate agent. Conversely, if the culture shows a very sensitive organism, I may recommend de-escalating to a narrower-spectrum antibiotic (antimicrobial stewardship).
  • 4. IV Specifics Check (The Recipe): Is the standard diluent (e.g., NS or D5W) and volume (e.g., 100 mL) appropriate? What is the standard infusion duration? For cefepime, this is typically 30 minutes, but for severe infections, an “extended infusion” over 3-4 hours might be used to optimize its time-dependent killing. I must ensure this is correct.
  • 5. Duration & Follow-up Check: Is there a clear duration of therapy, or is the order indefinite? I will make a note to follow up on culture results in 48-72 hours to ensure the therapy is de-escalated or stopped appropriately.

Part 2: Continuous Infusions

The High-Stakes World of Titratable Drips

Continuous infusions are medications administered as a continuous, titratable “drip,” primarily in the ICU. These are some of the highest-risk medications in the hospital, as a small error in concentration or rate can have immediate and catastrophic consequences. Your verification of these orders must be flawless.

Retail Pharmacist Analogy: Driving a High-Performance Car

Verifying an intermittent IV is like setting a cruise control. Verifying a continuous infusion is like actively driving a Formula 1 car. You are no longer “setting and forgetting.” You are verifying the parameters that allow the driver (the nurse) to make constant, real-time adjustments to the accelerator (the infusion rate) based on feedback from the dashboard (the patient’s vitals). Your job is to ensure the car’s systems are perfectly calibrated and that the safety limits (min/max rates) are in place to prevent a crash.

Masterclass: Common Continuous Infusions

Infusion TypeYour Verification Checklist & Clinical Pearls
A. Vasopressors (e.g., Norepinephrine)
  • Standard Concentration: Is it a standard concentration (e.g., 8mg/250mL)? This is a critical safety check.
  • Route: Must be a central line. You must verify this.
  • Math Check: Independently calculate the initial rate in mL/hour.
  • Complete Titration Parameters: Must include a start rate, goal (e.g., MAP > 65), titration increment, and max rate.
B. ICU Sedatives (e.g., Propofol)
  • Propofol: Monitor triglycerides. Account for lipid calories. Watch for PRIS.
  • Dexmedetomidine: Monitor for bradycardia and hypotension.
  • Analgesia First: Ensure an opioid is on board before starting a sedative.
C. IV Insulin Drip
  • Standard Concentration: Must be 1 unit/mL (100 units/100mL).
  • Protocol Adherence: The order must specify which hospital protocol to use.
  • The Transition Plan: You must champion the crucial 1-2 hour overlap between starting subcutaneous basal insulin and stopping the IV drip to prevent rebound hyperglycemia/DKA.
D. IV Heparin Drip
  • Correct Protocol: Is it the right weight-based protocol for the indication (DVT/PE vs. ACS)?
  • Calculations: Independently recalculate the initial bolus and infusion rate.
  • Monitoring Orders: Verify orders for baseline CBC/aPTT and serial aPTT checks every 6 hours.

Part 3: Advanced Pain Management

PCA & Epidurals

Patient-Controlled Analgesia (PCA) and Epidurals are highly effective for severe pain but are among the highest-risk therapies. Your verification is a zero-error task.

Retail Pharmacist Analogy: The High-Security Vending Machine

A PCA pump is like a high-security vending machine. The patient can only get a small amount at a time (demand dose), the machine won’t dispense again for a set period (lockout), and it won’t give out more than a total amount per hour (hourly limit). Your job is to be the master technician who programs these safety limits into the machine so that it’s impossible for the patient to accidentally “empty the vault” and cause a dangerous overdose.

Anatomy of a PCA Order: A Multi-Point Safety Check

You must verify every single component of this complex order.

  • 1. Drug and Concentration: Must be a hospital-standard concentration (e.g., Hydromorphone 1 mg/mL).
  • 2. Demand Dose: The dose the patient receives per button push (e.g., 0.2 mg).
  • 3. Lockout Interval: The minimum time between doses (e.g., 8 minutes).
  • 4. Basal Rate (Optional): A continuous infusion. This is a very high-risk feature that should only be used in opioid-tolerant patients with continuous respiratory monitoring.
  • 5. Hourly/4-Hour Limit: The maximum total dose the patient can receive. This is your ultimate safety net.
  • 6. Mandatory Rescue Orders: Every PCA order must be accompanied by an order for naloxone and clear monitoring parameters (e.g., continuous pulse oximetry, hourly sedation checks).
Deep Dive: Epidural Analgesia
  • Preservative-Free is Mandatory: This is an absolute, non-negotiable rule. All medications for epidural or spinal use must be preservative-free to prevent irreversible nerve damage. You are the final check.
  • Concentration Check: You must verify the concentrations of both the opioid and the local anesthetic. A decimal point error can be catastrophic.
  • Monitoring: Ensure there are clear orders for monitoring motor function, sensation, and blood pressure.

Part 4: Oral & Enteral Orders

Beyond the Simple Swallow

While oral orders seem familiar, the inpatient setting introduces new complexities, particularly for patients with feeding tubes. Furthermore, promoting the timely conversion from IV to oral therapy is a major pharmacist role.

Retail Pharmacist Analogy: The Master Plumber

Think of yourself as a master plumber who knows what can safely go down different types of pipes (the patient’s GI tract and feeding tubes). You know that some items (extended-release tablets) will clog the system or cause a dangerous backup. Your job is to inspect every medication and ensure it’s compatible with the specific “pipe” it’s intended for.

The “Do Not Crush” Dilemma & Feeding Tubes

Your critical role is to identify medications that cannot be crushed for tube administration:

  • Extended-Release (ER/SR/XL): Crushing causes potentially toxic “dose dumping.”
  • Enteric-Coated (EC): Crushing destroys the protective coating.
  • Hazardous Drugs: To prevent staff exposure.

When you identify such an order, you must intervene and recommend a safe alternative (e.g., switch ER metoprolol to IR metoprolol given more frequently).

The IV-to-PO Conversion Initiative

Switching from IV to PO is a key pharmacist-driven initiative to reduce cost, infection risk, and length of stay. You identify candidates and recommend the switch.

Conversion TypeExamples & Your Action
1:1 Conversions (High Bioavailability) Levofloxacin, Metronidazole, Doxycycline, Fluconazole. Your action is to recommend a direct, dose-for-dose switch once the patient is stable and can tolerate PO.
Conversions Requiring Dose Adjustment Furosemide: Oral bioavailability is ~50%. The dose must be doubled (e.g., 40 mg IV ≈ 80 mg PO).
Ciprofloxacin: Oral bioavailability is ~70% (e.g., 400 mg IV ≈ 500 mg PO).