CHPPC Module 38, Section 2: Pharmacist’s Daily Surveillance Routine
MODULE 38: ADR & MEDICATION ERROR REPORTING

Section 38.2: Pharmacist’s Daily Surveillance Routine: Triggers and Tools

Learn to proactively hunt for adverse events. This section covers the use of “trigger” reports (e.g., abrupt medication stops, orders for reversal agents like naloxone or vitamin K) and other software tools to systematically scan the hospital for signs of medication-related harm.

SECTION 38.2

Pharmacist’s Daily Surveillance Routine: Triggers and Tools

From Reactive Problem-Solver to Proactive Safety Detective.

38.2.1 The “Why”: Moving from Passive to Proactive

Traditionally, adverse drug event detection has been a passive, reactive process. A nurse or physician would notice a patient having a reaction, connect it to a medication, and then (maybe) report it to the pharmacy. This method is notoriously unreliable and captures only a tiny fraction of the actual medication-related harm that occurs. It relies on busy frontline clinicians to not only spot an event but also to have the time and inclination to report it. Modern hospital pharmacy practice flips this model on its head. The new paradigm is active surveillance, and the pharmacist is the primary driver.

Instead of waiting for reports to come to us, we now use the power of the electronic health record (EHR) to proactively hunt for the clinical signals of adverse events. This is accomplished through the use of “trigger tools.” A trigger is simply a clinical clue that suggests an ADE *might* have occurred. An order for naloxone doesn’t prove that a patient had respiratory depression, but it’s a very strong clue. A sudden spike in a patient’s serum creatinine doesn’t prove it was caused by a drug, but it’s a signal that warrants investigation. By systematically reviewing these triggers every single day, the pharmacist becomes a clinical detective, sifting through the hospital’s data to find patients who may be experiencing medication-related harm, often before the primary team is even aware of the connection. This proactive approach is the foundation of a modern, data-driven medication safety program.

Retail Analogy: The Refrigerator Temperature Log

In your retail pharmacy, you didn’t wait for a patient to complain that their insulin wasn’t working to discover your refrigerator was broken. That would be a reactive, catastrophic failure. Instead, you had a proactive surveillance system: the temperature log. Every morning, a technician’s first task was to check the temperature and document it. If the temperature was out of range (a “trigger”), it didn’t automatically mean the insulin was ruined. It meant you had to investigate. You would check if the door was left ajar, review the temperature trend, and determine if the medications were still viable. You used a small, simple piece of data—the temperature reading—to protect thousands of dollars of inventory and ensure patient safety.

Think of the pharmacist’s daily trigger report as a clinical temperature log for the entire hospital. You are scanning for signals that are out of range—a naloxone order, a high INR, a low blood sugar—to identify potential problems before they escalate into catastrophic failures.

38.2.2 The Trigger Tool Philosophy: Signal vs. Noise

It is critical to understand that a trigger is not a diagnosis; it is an alert that prompts a closer look. A well-designed trigger tool is a balance between sensitivity (the ability to capture most of the true ADEs) and specificity (the ability to filter out “false positives” or clinical noise). If your trigger list is too broad, you will spend your entire day chasing down hundreds of alerts that turn out to be clinically insignificant. This leads to alert fatigue, and soon, all alerts are ignored. If your trigger list is too narrow, you will miss important events.

Most hospitals have a dedicated team (often including a pharmacist informaticist and the medication safety officer) that builds and refines these trigger reports. Your daily routine will consist of running these reports, which are essentially custom-built patient lists, and performing a targeted chart review on each patient who appears on the list. Your goal is to quickly and efficiently determine if the trigger represents a true ADE that requires documentation and intervention.

38.2.3 Masterclass Table: Common ADR Triggers & The Pharmacist’s Investigation

This table outlines some of the most common and effective triggers used in hospital surveillance. Your daily routine will involve systematically working through a list generated by these (and other) rules.

Trigger Category & Example Potential Adverse Event(s) The Pharmacist’s Investigative Workflow Common Culprit Drugs
Antidote / Reversal Agent Orders
e.g., Naloxone, Flumazenil, Vitamin K, Digibind, Praxbind		 Opioid-induced respiratory depression; Benzodiazepine overdose; Warfarin over-anticoagulation (bleeding); Digoxin toxicity; Dabigatran-related bleeding.
  1. Review the MAR: What was the timing of the trigger drug administration relative to the suspected culprit?
  2. Review provider/nursing notes: Look for documentation describing the event (e.g., “patient unarousable,” “RR of 6,” “hematemesis”).
  3. Check vital signs and relevant labs (e.g., INR for Vitamin K, digoxin level).
  4. Was the event a preventable error (e.g., overdose) or a non-preventable reaction?
 Opioids (morphine, hydromorphone), Benzodiazepines (lorazepam, midazolam), Warfarin, Digoxin, Dabigatran.
“Rescue” Medication Orders
e.g., IV/IM Diphenhydramine, Epinephrine, IV Corticosteroids		 Acute allergic reaction or anaphylaxis; Severe infusion reaction.
  1. Review the MAR for any new medications started within the last few hours, especially IV antibiotics or biologics.
  2. Look for notes describing a rash, hives, shortness of breath, or hypotension.
  3. Check vital signs for tachycardia or hypotension.
  4. Classify the reaction: is it a true allergy or a predictable infusion reaction? Document accordingly.
 Beta-lactam antibiotics, Vancomycin (“Red Man Syndrome”), Monoclonal antibodies (-mabs), Chemotherapy agents.
Sudden Laboratory Changes
e.g., Serum Creatinine doubles or rises >0.5 mg/dL		 Drug-induced nephrotoxicity (Acute Kidney Injury – AKI).
  1. Review the patient’s full medication list for all potential nephrotoxins.
  2. Note the start dates. Did the rise in SCr correlate with the initiation of a new, high-risk drug?
  3. Assess for synergistic toxicity (e.g., a patient on vancomycin AND piperacillin-tazobactam).
  4. Is the dose appropriate for the patient’s baseline renal function?
  5. Formulate a recommendation: Discontinue the agent? Adjust the dose? Increase hydration?
 Vancomycin, Aminoglycosides, Piperacillin-Tazobactam, NSAIDs, ACE Inhibitors/ARBs, IV contrast dye.
Sudden Laboratory Changes
e.g., Platelets fall >50% from baseline		 Drug-induced thrombocytopenia, specifically Heparin-Induced Thrombocytopenia (HIT).
  1. Confirm the patient is on heparin or LMWH. Check the start date (HIT typically occurs 5-10 days after starting).
  2. Calculate the “4T score” to assess the pre-test probability of HIT.
  3. Immediately contact the primary team to recommend stopping all heparin products and ordering confirmatory HIT lab tests.
  4. Recommend starting a non-heparin anticoagulant (e.g., argatroban, bivalirudin) if the patient still requires anticoagulation.
 Heparin (unfractionated and LMWH).
Abrupt Medication Stop Orders
e.g., A newly started ACE inhibitor is discontinued within 48 hours.		 Intolerance or acute adverse event (e.g., angioedema, hyperkalemia, acute kidney injury).
  1. Review the labs around the time the drug was stopped (e.g., check potassium and SCr).
  2. Read the provider’s progress note for the day the drug was stopped. It will often state the reason (e.g., “stopping lisinopril due to cough” or “due to worsening AKI”).
  3. Ensure the reaction is documented correctly (e.g., angioedema is an allergy, cough is an intolerance).
 ACE Inhibitors, Antidepressants (intolerance), Statins (myalgias), Allopurinol (rash).

38.2.4 Beyond Triggers: Other Surveillance Methods

While trigger reports are your primary hunting tool, a well-rounded surveillance routine incorporates other methods to gather clinical intelligence.

  • Targeted High-Risk Drug Lists: Most EHRs can generate daily lists of all patients on specific high-risk medications (e.g., “All patients on a heparin infusion,” “All patients on warfarin with an INR > 4,” “All patients receiving chemotherapy”). Reviewing these lists allows you to focus your attention on the patients most likely to suffer harm and ensure their monitoring is appropriate.
  • Interdisciplinary Rounds: Your participation in rounds is a form of active surveillance. This is where you gather the “soft data” that reports can’t capture. You might hear a nurse say, “Mr. Smith in room 204 seems much more confused today,” which could be the first signal of an adverse effect from a newly started anticholinergic medication.
  • Microbiology Report Review: A daily review of microbiology culture and sensitivity reports is essential. By comparing the patient’s bug-drug match, you can identify opportunities to de-escalate broad-spectrum antibiotics, or more critically, identify situations where a patient is on an antibiotic to which their pathogen is resistant—a form of medication error that can lead to significant harm.
The Challenge of “Signal vs. Noise”

As you become proficient in your surveillance routine, you will develop a crucial skill: quickly differentiating a meaningful clinical signal from background noise. Not every diphenhydramine order is an allergic reaction (it could be for sleep), and not every increase in creatinine is drug-induced. The art of surveillance is learning to use the trigger as a starting point and then rapidly integrating other clinical data—labs, notes, vital signs—to build a complete picture and decide if an intervention is warranted. This skill is what separates a novice pharmacist from an expert clinical detective.

Your Role as a Clinical Sentinel

A daily surveillance routine is more than a checklist; it is a professional mindset. It reframes your role from someone who simply processes orders to someone who actively protects patients by seeking out potential harm. By dedicating a structured part of your day to this “detective work,” you become a clinical sentinel for the entire hospital. You will catch problems earlier, prevent harm more effectively, and generate the high-quality data your organization needs to continuously learn and improve. This proactive approach is the pinnacle of modern, safety-focused clinical pharmacy practice.