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MODULE 32: FORMULARY, NON-FORMULARY & THERAPEUTIC INTERCHANGE—WITHOUT FRICTION
Section 32.4: Communicating Changes to Bedside Staff & Patients
Closing the loop: The art of ensuring a behind-the-scenes decision is understood and safely implemented at the point of care.
SECTION 32.4
Communicating Changes to Bedside Staff & Patients
From decision to action: ensuring clarity, preventing confusion, and building trust.
32.4.1 The “Why”: The Last Mile of Medication Safety
You have successfully navigated a complex clinical scenario. You’ve identified a non-formulary order, “read the room” to understand the prescriber’s intent, and masterfully pitched a therapeutic interchange based on evidence, cost, and availability. You have changed the order in the computer system. In your mind, the process is complete. This is a dangerous and common cognitive error. In reality, you have only completed the first 90% of the task. The last, most critical 10%—the “last mile” of medication safety—is effective communication. A decision made in the pharmacy is clinically meaningless until and unless it is clearly understood, accepted, and correctly acted upon by the nurse at the bedside, and ideally, understood by the patient who is the ultimate recipient of the care.
Failure to close the communication loop is a primary source of medication errors and interprofessional friction. Imagine a nurse who goes to the automated dispensing cabinet (ADC) expecting to pull esomeprazole, only to find the drawer empty and a different drug, pantoprazole, in its place. Her first thought is not, “Ah, a brilliant therapeutic interchange!” Her first thought is, “Is this a stock-out? Is this a mistake? Did pharmacy verify the wrong drug?” This moment of confusion erodes trust, delays medication administration, and creates unnecessary work as she now has to stop what she is doing and call the pharmacy for clarification. In a worse scenario, if the dose or frequency of the new drug is different, she may administer it incorrectly, leading to patient harm.
This section is a masterclass in the art of “closing the loop.” Your goal is to make your communication so clear, concise, and targeted that it becomes an invisible and seamless part of the workflow. You must learn to anticipate the questions and concerns of your audience—the nurse, the provider, and the patient—and proactively provide the answers. Effective communication is not a “soft skill” in hospital pharmacy; it is a core technical competency that is as important as knowing the difference between two drug classes. It is the final, critical step that turns a good decision into a safe and effective outcome.
Retail Pharmacist Analogy: The “Your Doctor Switched Your Medicine” Conversation
A patient drops off a prescription for lisinopril 20 mg. An hour later, you get a call from their cardiologist. “Hi, this is Dr. Smith’s office. We just saw Mrs. Johnson. She’s developing a bit of a cough on the lisinopril, so we want to switch her to losartan 100 mg instead. Can you just change that prescription for her?” You agree, make the change, and fill the losartan.
Now, Mrs. Johnson comes to pick up her prescription. What do you do?
- The Ineffective Approach: You simply hand her the bag. She gets home, opens it, and sees a different pill. She’s confused. “This isn’t my lisinopril. The pharmacy made a mistake.” She doesn’t take it, her blood pressure is uncontrolled, and she calls the doctor’s office angry and frustrated the next day. The loop was never closed.
- The Effective Pharmacist Approach: When she comes to the counter, you say, “Hi Mrs. Johnson. I have your blood pressure medication ready, and I just wanted to let you know about a change. Your doctor, Dr. Smith, called us a little while ago. He was concerned you were developing a cough from the lisinopril, so he has switched you to a new medication in the same family called losartan. It works just as well for your blood pressure but without the risk of a cough. We’ve updated your profile, so this is the one you’ll be taking from now on. The pill will look different, but it’s the right one. Do you have any questions for me about it?”
This is closing the loop. You have anticipated the patient’s confusion, explained the “why” behind the change, confirmed the action, and invited questions. You have prevented a medication error and built trust. This is the exact same communication package you will deliver to the bedside nurse and, when appropriate, to the patient in the hospital.
32.4.2 Your Primary Audience: Communicating with the Bedside Nurse
The bedside nurse is the single most important recipient of your communication. They are the final person in the medication use process and the one who will physically administer the drug. Any confusion on their part presents a direct and immediate risk to the patient. Your communication with them must be tailored to their needs: it must be clear, concise, actionable, and delivered in a way that respects their workflow.
The Cardinal Sin: The “Stealth Edit”
The most dangerous and professionally disrespectful thing you can do is to change an active medication order in the electronic health record (EHR) without directly notifying the nurse responsible for administering it. A nurse may have already seen the original order, mentally prepared to give it, and may not see your silent change in the system. They might administer the original drug from an override or a previous dispense, leading to a wrong-drug error. Every active medication order change requires a direct, closed-loop communication with the nurse. There are no exceptions to this rule.
Masterclass Table: Communication Methods & Scripts for Nurses
| Method | When to Use It | The “Good vs. Bad” Script |
|---|---|---|
| The EHR Comment/Note | Best for automatic, protocol-driven interchanges where the change is straightforward and does not alter the dose timing or administration technique. This creates a permanent, documented record. |
BAD: “Swapped per protocol.” (This is lazy and unhelpful. It doesn’t explain what or why.) GOOD: “Therapeutic Interchange: Per hospital protocol, non-formulary esomeprazole IV has been changed to our formulary pantoprazole 40mg IV daily. This is a clinically equivalent PPI. No change in administration time needed. – [Your Name], PharmD” |
| The Direct Phone Call | Use for any change that is time-sensitive, complex, or could cause confusion. This includes changes in dose, frequency, or when you need to confirm information with the nurse. |
BAD: “Hey, I changed the Zosyn order for your patient in 412.” (Which patient? What was the change? Why?) GOOD: “Hi, this is [Your Name], the pharmacist for 4 East. I’m calling about the new Zosyn order for Mr. Smith in room 412. I’ve adjusted the dose based on his latest creatinine clearance. The new dose is now 3.375 grams IV every 8 hours instead of every 6. I’ve updated the order in the computer and released the next dose from the ADC. The next due time is now 1800.” |
| Face-to-Face (At the Unit/Bedside) | The gold standard for high-risk or complex changes, especially if you are already on the unit. It shows the highest level of collaboration and allows for immediate clarification and questions. |
BAD: (Walking by the nursing station) “Hey, I switched that drip on your guy in room 2.” (This is too casual and lacks critical detail.) GOOD: (Approaching the nurse) “Hi, Sarah. I just wanted to give you a heads-up on Mr. Davis in room 2. The team wanted to switch him from the diltiazem drip to an oral agent. I’ve spoken with the doctor and we’ve discontinued the drip and ordered amlodipine 5mg daily starting now. I’ve already verified the first dose. This will make your life much easier than managing that infusion!” |
32.4.3 The Final Check-In: Communicating with the Prescriber
While your primary negotiation may have already happened with the prescriber, closing the loop is still an important sign of professionalism and a key safety step. The level of communication required depends on the type of change that was made.
The Principle of “Inform vs. Discuss”
Your communication strategy with the prescriber should be guided by the nature of the change. Not every swap requires a lengthy conversation.
- INFORM: Use for automatic therapeutic interchanges that are approved by the P&T Committee and written into hospital policy. The decision has already been made at an institutional level. Your communication is a professional courtesy to inform the provider of the action you have taken based on that policy. This can often be done passively via an EHR note.
- DISCUSS: Use for any pharmacist-driven recommendation that is not covered by an automatic interchange policy. This is a situation where you are using your clinical judgment to suggest a change. This requires a direct conversation (phone call or face-to-face) to present your evidence and get the provider’s verbal agreement before making the change.
32.4.4 The Forgotten Stakeholder: Communicating with the Patient
This is an advanced practice skill that is often overlooked in busy hospital environments, but it is one that can have a profound impact on patient satisfaction, medication adherence, and safety, particularly at the point of discharge. Patients are increasingly engaged in their own care. They often know the names, shapes, and colors of their home medications. When they are in the hospital and receive a pill that looks different, it can be a source of significant anxiety and confusion.
While the primary responsibility for patient communication lies with the physician and the nurse, the pharmacist has a unique opportunity to provide expert clarification about medication changes. A brief, proactive conversation with an engaged patient about a formulary swap can prevent confusion, build trust, and smooth the transition of care.
When and How to Engage the Patient
You do not need to speak with every patient about every change. The key is to identify high-risk scenarios where a formulary change could lead to confusion after discharge.
High-Risk Scenarios for Patient Communication
Prioritize a brief conversation with the patient or their family in these situations:
- “Continuity of Care” Swaps: The patient is on a non-formulary medication at home (e.g., rosuvastatin) and you have switched them to the formulary alternative (atorvastatin) for their hospital stay. They need to know to go back to their home medication upon discharge.
- High-Risk Medication Changes: When you have changed a critical medication like an anticoagulant, antiplatelet, or antidiabetic agent, even if it’s within the same class.
- Brand to Generic Switches: When a patient is adamant about taking a brand-name drug and you have swapped them to the generic equivalent.
The Patient-Friendly Script
The conversation should be simple, reassuring, and clear. Avoid jargon.
Pharmacist: “Hi Mr. Williams, I’m [Your Name], one of the pharmacists here at the hospital. I just wanted to pop in for a moment and talk about your cholesterol medication. I know you normally take Crestor at home, which is a great medication. While you’re here with us in the hospital, we use a different one from the same family called atorvastatin. It does the exact same job to protect your heart, it’s just the one the hospital has on its menu. The most important thing to know is that when you get discharged, you should go right back to taking your Crestor at home as prescribed. This is just a temporary switch for while you’re here. Does that make sense?”
This simple, two-minute conversation accomplishes several critical goals: it alleviates the patient’s potential anxiety about receiving a “different” medicine, it educates them about the concept of a hospital formulary, it prevents a potential medication error at discharge (e.g., the patient thinking they should now take both), and it positions you, the pharmacist, as a caring and accessible member of their healthcare team.
