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MODULE 42: MASTERING CLINICAL SURVEILLANCE: FROM DATA TO INTERVENTION
Lesson 7: Communication & Documentation
The art and science of high-stakes professional communication. This lesson will transform you from a medication expert into a medication safety leader by mastering structured communication, closed-loop verification, and forensic documentation.
LESSON 7
Surveillance of Communication & Documentation
From Counselor to Communicator-in-Chief: Architecting Medication Safety Through Words.
The “Why”: Words are the Most Powerful Drugs We Administer
As a retail pharmacist, you are already a master communicator. You have perfected the art of explaining complex medication regimens in simple terms, of building trust with anxious patients, and of concisely clarifying a prescription with a busy prescriber’s office. These skills are the bedrock of your professional practice. In the hospital, this foundation becomes even more critical, but the context and the stakes are amplified exponentially.
Hospital communication is a chaotic, multi-layered, and asynchronous web of interactions. Information flows through pagers, secure text messages, electronic health record notes, phone calls, and hallway conversations. The signal-to-noise ratio is dangerously low. A vague recommendation, a misunderstood order, or an undocumented conversation can have catastrophic consequences. In this environment, your ability to communicate with structure, clarity, and precision is not a “soft skill”—it is a core clinical competency as important as your knowledge of pharmacokinetics.
This lesson is about weaponizing your communication skills for the hospital environment. We will deconstruct the tools and techniques used by high-reliability organizations to ensure that every message is sent, received, understood, and acted upon correctly. You will learn to use the SBAR framework to structure your thoughts into powerful, actionable recommendations. You will master closed-loop communication to eliminate ambiguity and confirm understanding. And you will learn to view documentation not as a chore, but as a critical tool for creating a permanent, unambiguous record of your clinical reasoning and interventions. By mastering these skills, you will elevate your practice from a medication expert to a true leader in patient safety.
Retail Pharmacist Analogy: From a Two-Way Radio to a Carrier Strike Group’s Communication Hub
Communication in your retail pharmacy is like using a high-quality, dedicated two-way radio. When you need to talk to a patient, you have a direct, one-on-one channel at the counseling window. When you need to clarify a script, you call the prescriber’s office—another direct, point-to-point communication. The conversations are important, but they are generally linear, predictable, and involve a small number of people.
Medication-related communication in the hospital is like being the communications officer for a naval aircraft carrier strike group during combat operations. You are at the center of a massive, chaotic, and high-stakes information hub. You have incoming messages from every direction: the pilot of a landing jet (the bedside nurse), the captain of a nearby destroyer (the consulting specialist), the admiral of the fleet (the attending physician), and air traffic control (the OR). Messages are coming in through a dozen different channels—radio, secure chat, signal lamps, verbal shouts on the bridge. They are often fragmented, filled with jargon, and delivered under extreme time pressure.
Your job is not just to listen; it is to receive, interpret, prioritize, and transmit critical information with absolute precision. You can’t just say, “I think we should turn left.” You must use a structured format: “This is the communications officer. (Situation) We have an unidentified contact bearing 090. (Background) It is not responding to hails and is approaching at high speed. (Assessment) I believe this is a hostile threat. (Recommendation) I recommend we alter course to 180 and raise shields.” You then wait for the captain to say, “Confirm, altering course to 180 and raising shields.” That is structured, closed-loop communication. This lesson will train you to be that officer, ensuring that in the chaos of clinical care, the message of medication safety is always transmitted with perfect clarity.
42.7.1 SBAR: The Universal Language of Patient Safety
The SBAR framework is the most powerful communication tool in your hospital arsenal. It is a structured method for communicating critical information that was originally developed by the U.S. Navy for use on nuclear submarines, where a misunderstanding could have unimaginable consequences. It was later adapted for healthcare to solve the same problem: a lack of clear, concise communication leading to patient harm. SBAR is not just a technique; it is a mental discipline that forces you to organize your thoughts before you speak or type, ensuring your message is focused, actionable, and free of ambiguity.
Deconstructing the Framework
SBAR consists of four distinct components. Mastering the purpose of each is the key to effective communication.
| Component | Purpose | Guiding Question | Pharmacist-Specific Example |
|---|---|---|---|
| Situation | A concise statement of the problem. This is the “headline” that grabs the listener’s attention and tells them why you are contacting them. | “What is happening right now?” | “Dr. Adams, this is John the pharmacist. I’m calling about your patient Jane Doe in room 402. I have a critical lab value to report.” |
| Background | Brief, relevant clinical context. This provides only the information needed to understand the problem. No rambling. | “What is the relevant background information?” | “She is a 78-year-old female admitted for pneumonia, being treated with vancomycin. We drew a trough level this morning.” |
| Assessment | Your professional assessment of the situation. This is where you connect the dots and state what you think the problem is. | “What do I think the problem is?” | “The vancomycin trough came back at 28 mg/L, which is significantly supratherapeutic. Given that her creatinine has also increased from 1.1 to 1.8 since admission, I believe she is developing an acute kidney injury, likely secondary to vancomycin toxicity.” |
| Recommendation | A clear and specific “ask.” State what you need the other person to do. This is the most important and often-missed step. | “What do I need from you?” or “What do I recommend we do?” | “I recommend we hold the next dose of vancomycin due at 10 AM and switch her to linezolid 600 mg IV Q12H for her MRSA coverage. I can enter that order for you to sign if you agree.” |
The Anti-SBAR: How Pharmacists Fail to Communicate
Without structure, our communication can become vague and ineffective, leading to frustration and potential errors. This is the “Anti-SBAR.”
The Anti-SBAR Example: “Hi Dr. Adams, this is John. I’m calling about the patient in 402. Her vanc level is high. Her creatinine is also up. The level is 28. Do you want to do anything with that?”
Why this is dangerous:
- No Situation: It starts with a name but no clear problem statement. The doctor has to guess why you’re calling.
- Disorganized Background: The information is fragmented and lacks context.
- No Assessment: The pharmacist just states facts (“level is high”) but does not offer a professional interpretation (“I believe this is drug-induced nephrotoxicity”).
- Missing Recommendation: The pharmacist asks an open-ended question (“Do you want to do anything?”). This shifts the cognitive load entirely to the busy physician, who may not have the time or mental bandwidth to formulate a plan from scratch. It invites a rushed, potentially unsafe decision.
Pharmacist SBAR Scripts for Common Scenarios
Practice using SBAR until it becomes second nature. Here are some templates for common pharmacist interventions.
Scenario 1: Clarifying an Ambiguous Order
“Hi Dr. Evans, this is the pharmacist. (S) I’m calling for clarification on a pain medication order for Mr. Michaels in 613. (B) He was just admitted from the PACU post-op knee replacement. You’ve ordered ‘oxycodone PRN pain.’ (A) To ensure safe and appropriate pain management, the order needs a specific dose, frequency, and route. (R) My recommendation is ‘oxycodone 5 mg PO every 4 hours as needed for moderate pain.’ Would you like me to place that order?”
Scenario 2: Recommending a Renal Dose Adjustment
“Dr. Chen, this is the pharmacist. (S) I am calling to recommend a renal dose adjustment for the enoxaparin on your patient, Mrs. Davis in the ICU. (B) Her creatinine has risen to 2.5 mg/dL today, and her calculated CrCl is now 25 mL/min. She is currently ordered for 80 mg SQ Q12H for her PE. (A) At her current level of renal function, the standard dosing will lead to drug accumulation and a very high risk of bleeding. (R) I recommend we change the order to enoxaparin 80 mg SQ once daily. I’ve also recommended we get an anti-Xa level in the morning to ensure she remains therapeutic. Can I make that change for you?”
42.7.2 Closed-Loop Communication: The Art of Verification
Using SBAR ensures you send a clear message. Closed-loop communication ensures the message was received and correctly understood. This is a simple but profoundly important safety technique that involves three steps: the sender initiates a message, the receiver accepts the message and confirms it by repeating it back, and the sender provides a final confirmation that the message was understood correctly. This process eliminates errors from mishearing, misunderstanding, or distraction.
The Danger of the Open Loop
An “open loop” is a communication that is sent into the void with no confirmation of receipt or understanding. It is one of the most common sources of medication errors, especially with verbal orders.
Masterclass Table: Open vs. Closed Loop Communication
| Scenario | Open Loop (Dangerous) Example | Closed Loop (Safe) Example |
|---|---|---|
| Accepting a Verbal Order | Physician: “Give the patient 10 of morphine IV now.” Pharmacist/Nurse: “Okay.” (Hangs up) Risk: Was that 10 milligrams or 10 milliliters? What if the standard concentration is 2 mg/mL? This could be a 10mg dose or a 20mg dose. |
Physician: “Give the patient 10 of morphine IV now.” Pharmacist/Nurse: “To confirm, you are ordering ten, one-zero, milligrams of morphine IV push for one dose now. Is that correct?” Physician: “That is correct.” |
| Clarifying an Infusion Rate | Pharmacist: “The new rate for the heparin drip is 12 an hour.” Nurse: “Got it.” Risk: 12 what? 12 units/kg/hr? 12 mL/hr? What if the pump is programmed in mL/hr but the order is in units/kg/hr? This leads to massive dosing errors. |
Pharmacist: “Per the protocol, the new heparin rate should be 1,200 units per hour. Based on our standard concentration of 100 units/mL, that is a pump rate of twelve, one-two, milliliters per hour.“ Nurse: “Okay, I understand. I will set the pump to 12 mL per hour.“ Pharmacist: “Thank you.” |
Key Phrases for Closing the Loop
Integrate these phrases into your daily practice until they are automatic.
- “Let me read that back to you to make sure I have it right…” (For any verbal order, without exception).
- “So, just to confirm, your recommendation is…” (When receiving a plan from a physician or another provider).
- “My understanding of the plan is X. Is that correct?” (A great way to verify your interpretation of a complex plan).
- When giving numbers, especially doses, spell them out or state the individual digits. Instead of “fifty,” say “five-zero milligrams.” Instead of “fifteen,” say “one-five milligrams.” This prevents sound-alike errors (fifty vs. fifteen).
42.7.3 Medication Reconciliation: Forensic Science for Patient Safety
Medication reconciliation is the formal process of creating the most complete and accurate list possible of a patient’s current medications, comparing it against the physician’s admission, transfer, and/or discharge orders, and reconciling any discrepancies. This sounds like a simple administrative task. In reality, it is one of the most cognitively demanding and highest-impact activities a pharmacist can perform. It is a forensic investigation into a patient’s medication history to prevent errors of omission, commission, and duplication.
The “Best Possible Medication History” (BPMH)
The foundation of good med rec is obtaining the BPMH. This requires using at least two sources of information, as no single source is ever reliable. Your job is to be a detective.
Masterclass Table: Sources for the BPMH Investigation
| Source | Strengths | Weaknesses | Pharmacist Detective Work |
|---|---|---|---|
| The Patient/Family Interview | The best source for adherence, OTCs, herbals, and “as needed” medication use. | Unreliable for exact doses, frequencies, or names. Patients often use brand/generic names interchangeably or describe meds by shape/color. | Use open-ended questions: “How do you ACTUALLY take your furosemide?” not “Do you take your furosemide every day?” The answer to the first is “Well, I take it when my ankles get swollen.” The answer to the second is “Yes.” |
| The Patient’s Pharmacy Fill History | Excellent for exact drug name, strength, and date of last fill. Helps identify multiple prescribers and pharmacies. | A filled prescription does not mean the patient is taking it. Does not include samples, OTCs, or meds from other pharmacies. | Look at the last fill date and days’ supply. “The pharmacy record shows you last filled your lisinopril 45 days ago for a 30-day supply. It seems you may have missed some doses. Can you tell me about that?” |
| The Patient’s Pill Bottles | Shows exactly what the patient has in their possession. Confirms drug, strength, and prescriber information on the label. | The sig on the bottle may not reflect what the patient is actually doing. The patient may have bottles from old, discontinued prescriptions. | “This bottle says to take one tablet daily, but you mentioned you take it twice a day. Can you tell me why the dose was changed?” This uncovers verbal instructions that were never updated on the script. |
| Prior Hospital/Clinic Records | Provides a list from a previous healthcare encounter. Can be a good starting point. | Often wildly out of date. The list is only as good as the reconciliation that was done at that time. Prone to copy-and-paste errors. | Treat with extreme skepticism. Use it as a clue sheet, not as a source of truth. Verify every medication against a second source. |
The Most Dangerous Discrepancies
Your surveillance should be laser-focused on “high-risk” medications where an error could cause significant harm.
Your Med Rec “Most Wanted” List:
- Omission of Anticoagulants/Antiplatelets: A patient with A-fib whose apixaban is missed on admission is at high risk for a stroke. This is a top priority to verify.
- Duplication of Insulin: The patient takes Lantus at home, but the admitting physician orders both Lantus and Levemir. This is a recipe for severe hypoglycemia.
- Incorrect Opioid Dose: A patient is on chronic, high-dose oxycodone at home. The admitting physician, unaware of their tolerance, orders a standard low dose. This leads to undertreated pain and withdrawal. The reverse (ordering a high dose for an opioid-naive patient) is equally dangerous.
- Missed Immunosuppressants: A transplant patient whose tacrolimus is missed on admission is at risk for organ rejection.
- Continuation of Held Meds: A patient’s methotrexate was held by their rheumatologist last week. If this is not discovered, it may be automatically continued on admission, leading to toxicity.
42.7.4 Documentation: If You Didn’t Write It, It Didn’t Happen
In the fast-paced hospital environment, verbal conversations are essential but fleeting. Documentation is the act of creating a permanent, legal record of your clinical activities, assessments, and recommendations. It is your primary tool for communicating your value to the rest of the healthcare team, for ensuring continuity of care, and for protecting yourself and your patient. A well-written pharmacist note is a powerful instrument that clarifies complex medication issues and guides future decision-making.
The Pharmacist’s Note: Moving Beyond “Order Verified”
Your thought process is valuable. Documentation is how you share it. A good note should be concise, clear, and follow a logical structure. While formats vary, a SOAP note (Subjective, Objective, Assessment, Plan) is a great mental model to use.
Masterclass Table: Architecting a High-Impact Pharmacist Note
| SOAP Component | Content | Example |
|---|---|---|
| Subjective | Patient-reported information (if relevant). Often not included in pharmacist notes unless it’s the primary reason for the consult (e.g., patient reports side effect). | “Patient reports nausea after her morning dose of metformin.” |
| Objective | Hard data: lab values, vital signs, medication administration records, diagnostic test results. | “Patient is on vancomycin 1.5g IV Q12H for MRSA bacteremia. This AM’s trough was 28 mg/L (goal 15-20). SCr has increased from a baseline of 1.1 to 1.8 today.” |
| Assessment | Your clinical evaluation. This is the most important part of the note. Synthesize the subjective and objective data to state the medication-related problem. | “Supratherapeutic vancomycin level is likely contributing to an acute kidney injury. The current regimen is unsafe to continue.” |
| Plan | Your specific, numbered recommendations. State exactly what you did or what you recommend be done. |
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