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MODULE 3: THE HEART OF THE JOB
Section 4: Common Problems & How to Solve Them
Perfectly written orders are the exception, not the rule. The true measure of a hospital pharmacist is not just the ability to verify a correct order, but the skill and confidence to identify, investigate, and resolve an incorrect or incomplete one. This section is your practical, real-world playbook for becoming an expert problem solver.
Problem 1: Missing Information
The Incomplete Puzzle
The Retail Pharmacist Analogy: A Prescription with No Sig
Imagine receiving a prescription for “Lisinopril 10mg” with no directions. You wouldn’t guess “take one daily.” You would stop all action and immediately call the prescriber for clarification. An order in the hospital without the necessary clinical data (weight, labs) is the exact same situation. It is an incomplete, unverifiable instruction. Guessing is not an option.
This is the most common problem you will face. A prescriber, often in a hurry, will enter an order for a weight-based or renally-cleared drug without a recent weight or up-to-date labs in the chart. Your verification process must come to a hard stop. Proceeding is a breach of your professional duty.
Your Standard Operating Procedure (SOP) for Missing Data:
- Step 1: The Chart Investigation. Before you contact anyone, become a detective.
- For Missing Weight: Is there a weight in the nursing admission notes? The ER triage notes? An anesthesia record from a recent procedure? Sometimes the data exists, but it just hasn’t been entered into the main flowsheet yet.
- For Missing Labs: Check the lab section. Was a BMP or SCr already drawn but the result is still pending? If so, you can pend the order and wait for the result. If no lab has been ordered, you know your next step.
- Step 2: The Collaborative Contact. Your communication should be a request for teamwork, not an accusation.
- Contacting the Nurse First: For a missing weight, the patient’s nurse is your best first contact. A simple message: “Hi, this is [Your Name], the pharmacist. I have a new order for weight-based enoxaparin for your patient in room 502, but I don’t see a current weight in the chart. Would you be able to get a weight for me so I can verify this dose safely?” This is collaborative and patient-centered.
- Contacting the Prescriber: For a missing lab, the prescriber is the correct contact. Use the SBAR method: “(S) I have a new order for vancomycin for John Doe. (B) He was admitted yesterday, but there are no renal function labs on file. (A) I cannot safely verify this dose without a baseline serum creatinine. (R) Could you please place an order for a STAT BMP so we can get his antibiotic started?”
- Step 3: Document Everything. Document your actions in a clinical note. “Order for enoxaparin received. No current weight in chart. Paged RN Jane Smith to request patient weight for safe verification.” This creates a clear record of the delay and the reason for it.
Problem 2: Dose, Diluent, or Concentration Errors
The Flawed Recipe
The Retail Pharmacist Analogy: The Compounding Error
Imagine you are compounding a magic mouthwash. If the recipe calls for 10mL of nystatin suspension but you misread it as 100mL, the final product is wrong. If it calls for a saline base but you use a viscous lidocaine base, the stability and consistency are wrong. An IV order is a recipe, and you are the master compounder and final quality check. Any error in the recipe’s components (dose, diluent, concentration) makes the final product unsafe.
These are the classic “hard stop” errors that your clinical knowledge will allow you to catch. They represent a direct and immediate threat to patient safety.
Your Intervention Playbook for Recipe Errors:
| Error Type | Example | Your Thought Process & Intervention |
|---|---|---|
| Dose Out of Range | A gentamicin order for 5 mg/kg in a patient with a CrCl of 25 mL/min. | “Gentamicin is a highly toxic, renally-cleared drug. The standard dose is 5-7 mg/kg, but that is for extended-interval dosing in patients with good renal function. This patient needs a traditional, smaller dose given more frequently, or a significantly extended interval. I will calculate a new dose and interval based on the hospital’s protocol and recommend this change to the prescriber.” |
| Incorrect Diluent | An order for “Ampicillin 2g IV in D5W.” | “My ‘spidey sense’ is tingling. I know many penicillins have stability issues in dextrose. I will double-check a stability reference like Trissel’s. The reference confirms ampicillin stability is significantly reduced in D5W. This is a critical error. I will contact the prescriber and recommend changing the diluent to 0.9% NaCl.” |
| Excessive Concentration | An order for “Potassium Chloride 40 mEq IV in 100 mL NS to be given peripherally.” | “This is a major safety violation. Peripheral administration of potassium is extremely painful and carries a high risk of phlebitis. The maximum allowable concentration for peripheral infusion at my hospital is 10 mEq/100 mL. This order is four times that limit. I will contact the prescriber immediately. My recommendation will be to either infuse the 40 mEq in a larger volume of 400 mL, or to split it into four separate infusions of 10 mEq in 100 mL each.” |
Problem 3: Clinical Appropriateness Conflicts
The “Technically Correct, Clinically Wrong” Order
This is the most advanced category of problem-solving. It moves beyond math and stability into the realm of pure clinical judgment. These are orders that may be written correctly but are inappropriate for the patient’s clinical situation. Catching these errors is what separates a great pharmacist from a good one.
Your Clinical Judgment Playbook:
| Conflict Type | Example | Your Thought Process & Intervention |
|---|---|---|
| PRN Without Indication | “Ondansetron 4mg IV q6h PRN” | “This is a TJC violation and is unsafe. PRN for what? Nausea? Vomiting? Pre-chemotherapy? If the patient is also getting PRN promethazine, how does the nurse choose? I must contact the prescriber to add a specific indication, like ‘PRN for nausea/vomiting’.” |
| Duplicate Therapy | A patient has active, scheduled orders for both enoxaparin 1 mg/kg q12h and a continuous heparin infusion. | “This is a critical, high-risk duplication. The patient is receiving full therapeutic doses of two different anticoagulants, placing them at extreme risk of a major bleed. I must assume this is an error. I will immediately page the prescriber with the urgent recommendation to discontinue one of the agents immediately.” |
| Allergy Conflict | An order for ceftriaxone in a patient with a listed “penicillin allergy (hives).” | “The reported reaction is hives, which is a Type I IgE-mediated reaction. The cross-reactivity risk between penicillins and later-generation cephalosporins is low (<1-2%), but not zero. I need to assess the situation. Is this a life-threatening infection where ceftriaxone is the best drug? Or is there a safe, equally effective non-beta-lactam alternative (like a fluoroquinolone)? I will contact the prescriber to discuss the risk vs. benefit and offer alternatives." |
Problem 4 & 5: Proactive Interventions
IV-to-PO Conversions & Override Requests
The IV-to-PO Opportunity
This is not an “error” but a proactive, pharmacist-driven intervention to improve care. You are screening profiles for patients who are clinically stable and on an IV medication for which a highly bioavailable oral equivalent exists.
Your IV-to-PO Pitch (SBAR):
- (S) “Dr. Smith, this is [Your Name], the pharmacist, calling about your patient John Doe, who you are treating for cellulitis.”
- (B) “He has been on IV levofloxacin for 3 days. He is now afebrile, his WBC count is down-trending, and he is tolerating a regular diet.”
- (A) “He appears to meet the criteria for a safe switch from IV to oral therapy.”
- (R) “Since oral levofloxacin has nearly 100% bioavailability, I recommend we convert him to levofloxacin 750 mg by mouth daily to complete his therapy course. This will allow for removal of his IV line and may facilitate an earlier discharge. Would you like me to make that change for you?”
The Pyxis Override Request
An override is when a nurse needs to pull a medication from an ADC before a pharmacist has electronically verified the order. This is a high-risk process designed for true emergencies (e.g., getting dextrose for a hypoglycemic patient), but it is often used for non-emergent situations. You are the safety gatekeeper.
Your Override Triage Process:
- 1. Is this a true emergency? If the nurse needs a drug for a code, a seizure, or severe hypoglycemia, you approve it immediately while simultaneously reviewing the order.
- 2. Is this a “first dose”? If it’s the first dose of a STAT or NOW antibiotic or pain medication, it’s often appropriate to allow the override while you perform your full clinical check.
- 3. Is this a high-risk medication? You should have a much higher threshold for allowing overrides of anticoagulants, insulin, or narcotics. This requires an immediate, focused chart review and often a direct conversation with the nurse and/or prescriber before approval.
- 4. Is this a routine medication? If a nurse is requesting to override a routine, scheduled medication, this is often a sign of a system problem (e.g., the dose wasn’t delivered on time). You must investigate the root cause while still ensuring the patient gets their medication.
