How to Survive Your First Overnight Pharmacist Shifts
Steph’s Note: ‘Tis the season of new pharmacists embarking on residencies and new jobs (congratulations!!). Trust me when I say I know it can be daunting! (Confession: I somehow accidentally managed to avoid overnights for about the first 4 years of my career, but then when I was finally drafted, I’ll admit that I was pretty darn nervous. Actually if we’re being totally honest, I still felt that way during subsequent calls to overnight duty even years later!) So you’re not alone if you’re feeling this way. In fact, it’s pretty widespread.
To prove this point, we have a pharmacist from halfway across the world as our guest poster this week: Evangeline Chai. She works as an inpatient pharmacist in a public hospital in Southeast Asia. She’s excited to be contributing her first article to tl;dr pharmacy, and hopes these tips will make your pharmacy journey a little less stressful - and a lot more exciting!
Tell us what we need to do to survive 3rd shift, Evangeline!
You’ve just gotten your pharmacist license. You landed the job (woot!), have made it through orientation, and you’re just starting to get used to the hang of things in your hospital system. You’re getting to know a whole bunch of other health care professionals (physicians, nurses, dietitians, speech therapists, physical therapists, occupational therapists, medical social workers...and the list goes on.)
And now, just when you’re finally starting to recognize faces AND remember people’s names, your boss throws you the next challenge. It’s YOUR turn to be the night pharmacist-on-call. Which means...there’s only you (and perhaps another pharmacist) and a few pharmacy technicians to keep the whole hospital flush in appropriate medications. Key word: appropriate.
It’s you…for 10ish hours…facing the computer screen...and the meds...and the patients.
Depending on how you’re feeling, this might look like:
Or, perhaps you feel more like this:
Anyway, fret not.
Here are some tips to help you through these (potentially panic-inducing) night shifts.
Tip #1: Configure your EMR settings
This might sound basic, but once it’s done properly, it will save you A LOT of trouble. Because this is where you will get all of your patients’ clinical data.
Set up your verification work queue with the designated units you’re covering, so you can see all the orders waiting to be verified. If your EMR allows it, arrange “STAT” orders to be displayed at the top so you know which ones are really urgent. (Or at least you can decide if that acetaminophen order is actually STAT…)
And then you can sort the rest by the times they were ordered or by the time of next administration... Either way, you can figure out how to prioritize which orders to verify first.
It’s also helpful to include the drug name in your work queue, so you immediately know which lab parameters you need to assess before verifying the order.
Know where you can find the different pieces of information you need:
Emergency room and admission medical notes tell you the patient’s background and why he is admitted to the hospital. It gives you a clue about the drug’s INDICATION, and whether there are any CONTRAINDICATIONS which might prevent you from using certain drugs.
Sometimes even incomplete physician notes can be useful! The assessment and plan may not be finished, but you may be able to glean symptoms, past medical history, and/or chief complaint from the subjective section.
Lab results, vital signs, volume status, microbiological cultures, radiological scans (including those pending results) will help you know whether it’s SAFE to give this drug to the patient. Is the current therapy working (i.e., EFFECTIVE), and if not, do you have to adjust the current drug regimen?
The medication list will help you know whether the patient is taking any existing drugs which might INTERACT with the newly ordered drug. Is there any DUPLICATION with what’s currently prescribed?
Checking for active lines/drains (e.g., indwelling catheters, feeding tubes, central vs peripheral lines) will help you consider whether the medication is the most appropriate. Are there any special considerations that would change your choice of drug therapy?
For example, catheter-associated UTIs (CAUTIs) have different treatment considerations than non-CAUTIs.
If the patient has a feeding tube, what kind is it? Where does it start and end? Which drug formulations can be crushed and administered via the tube, and will the medication be absorbed from its exit spot in the GI tract?
If the patient has a central line, can/should you give the medication at higher concentrations than those for peripheral lines?
If your EMR has special “modules” such as Antibiotics Given, Capillary Blood Glucose Readings and Insulin Doses Given, etc., these are really helpful so you can see all this information at a glance. Definitely include these on your display screen.
For more tips on how to thoroughly but efficiently verify orders, check out this post.
Tip #2: Prioritize, prioritize, prioritize
When you have so many things to do at night, you need to know what’s urgent - and what’s not. And you need to know how to make these kinds of determinations.
For this, you can make use of the Eisenhower matrix (or what’s urgent vs. important):
(Image)
How might this matrix look in a pharmacy-on-call setting?
If there are issues which require further investigation (e.g., physically checking patient’s medication or reporting a medication error), it’s ok to hand these over to the pharmacist in-charge of the unit to follow up on during the day.
Once you get this right, organizing your work will become a breeze. It’s not always easy to make these determinations especially when you’re new, but with time and practice, it will become more second nature!
Tip #3: Have the resources you need on hand
It’s okay not to know everything.
Let me repeat: it’s okay not to know everything!!
We’re only human, and there’s absolutely no way for us to know every single thing about every disease state and every medication. It’s just the way it is. So if you can’t know everything, you absolutely need to know where to find the answers.
Know what resources you have and where you can find them – especially if you come across something so obscure you haven’t heard of it before and you need more information:
Drug references (e.g., Lexicomp, Micromedex, Facts and Comparisons, British National Formulary)
Clinical decision support databases (e.g., UpToDate)
Internal policies/protocols (e.g., drug formulary list, antibiotic guidelines, NPO protocol)
Treatment guidelines from national/international organizations
Pharmacy Cheat Sheets from the lovable folks at tl;dr pharamcy
Remember that you might not always be at your computer. So if you can have at least one or 2 more mobile references on your phone, that will likely come in handy.
Alternatively, you can make a “peripheral brain” at least to get you started. It’s not necessarily the best idea to keep forever as the info will probably become outdated unless you’re reeeeally good at updating periodically. But if you need this crutch for the things you know you may need quickly and just can’t ever remember off the top of your head, compile the info.
For example, if your institution has a dosing guide for ACLS medications, print and laminate it to put in your pocket. (If they don’t, consider compiling your own “cheat sheet” for those types of topics.) There is no shame in pulling out a reference during an emergency situation to triple check your medication dose and concentration.
Way better to take those extra 15 seconds to verify than to make a medication incorrectly!
And for everything else... there’s PubMed. Or Google (but check the reliability of the source! Dr. Google isn’t always trustworthy).
Perhaps there’s a little more in this differential… (Image)
The other type of help you should be familiar with is your personnel. Know who is working with you during a particular shift - and get to know them!
Maybe your technician has worked overnights for the past 20 years and can totally handle that call about the automated cabinet not working. Maybe the other overnight pharmacist who came from a different institution has already researched that anticoagulant reversal scenario.
Keep their phone numbers handy and know how to reach them.
On that note, you also need to know your help chain! Before your overnight shifts begin, you should ask questions. Who is your manager on call, and what are the department’s policies about contacting him/her overnight?
Finally, even if it feels like you are alone, remember that you’re never completely alone. Don’t think we pharmacists haven’t called another hospital pharmacy in the area to ask questions… because we totally have. There may not be another pharmacist on overnights with you at your specific hospital, but we’re willing to bet there’s someone on at a neighboring hospital who may be able to lend some help if you’re really stuck.
Better to feel a little awkward calling another pharmacist out of the blue than to make a mistake and hurt someone. (But definitely have done your research first before resorting to this!)
Tip #4: Beware of “dangers” out there
If an order doesn’t look right, pause, take a moment and look at it again. You might find something which, once corrected, could save your patient’s life (and your career).
Let’s have a look at drug therapy problems, and some examples of how things might go wrong…
Sometimes it’s a dosing issue. Even though computerized provider order entry (CPOE) is supposed to take care of problems like grams vs milligrams vs micrograms, it’s not 100%. Those orders for “50 tablets by mouth” still occasionally come through, usually because something was ordered in mg instead of mcg.
What your face should look like when you get an order for 10 tablets at a time - or a PO suppository. (Image)
No dose should ever require that many tablets… Even 5-10 tablets at a time should send up a red flag in your brain to check that dose again.
Also, make sure medications are appropriately dosed for renal and hepatic impairment.
Next, be sure to check out what product the system is selecting for dispensation. Many formulations, even if they have similar or the same active ingredients, are not interchangeable. Just think about all the different inhalers… MDIs (Evohaler) and DPIs (Accuhaler, Turbuhaler, Respimat, Ellipta, Breezhaler).
Consider immediate-release versus controlled-release medications, like carbamazepine, valproate, nifedipine, levodopa-benserazide, or levodopa-carbidopa. Their kinetics certainly aren’t the same, and dosing will vary between formulations.
Please check that the route of administration makes sense with the drug formulation. No PO suppositories, and if a tablet is ordered for rectal or vaginal administration, it may require a second look. (Not impossible…but rare. So look again.)
Look for therapeutic duplications. It used to be quite easy to find the enoxaparin with the warfarin because there weren’t too many PO anticoagulant options, but now with the apixabans, rivaroxabans, etc., things can get rather sneaky. Sometimes the prophylactic enoxaparin doesn’t get removed when the decision to start apixaban occurs.
On that note, when switching between drugs, whether it’s the above anticoagulants, from antibiotic A to B, from PO to IV, or to a different dose of the same medication, make sure the previous order is suspended - or (ideally) discontinued. Check to be sure the new order is appropriately timed too. If the patient received a dose of therapeutic enoxaparin at midnight, they don’t need that apixaban at 1 am…
One place this can be especially sneaky is in the ER. Because there are so many single doses administered there, they often fall off the active medication list. But if the patient received vancomycin x1 at midnight, again, they don’t need that q12h order to start at 1 am…
FYI, and I can’t emphasize this enough: check the MAR, not just the active medication list. You need to see all the once doses, the discontinued meds, etc. in order to make an informed decision about new medication timing. So don’t just rely on what’s actively on the list now to make those decisions.
Although sometimes it can feel like you’re playing detective, be sure that you can decipher an indication for each drug ordered. If after reviewing the chart you can’t come up with a reasonable explanation for the new medication, it’s time to clarify. Perhaps that’s a call to the nurse to see if she knows what’s going on, but it also may mean paging the provider.
It’s not too awfully common that that medication is ordered for the wrong patient, but it does still happen! And it certainly doesn’t hurt to ask if you’ve exhausted your chart detective work.
Check to see if there are short-term medications that aren’t required anymore, such as intra-operative orders, post-operative eye drops, or oral electrolytes replacements. Although many EMRs are getting better about having durations on these types of orders so that they don’t hang out foreverrrrr, it’s still not 100%. Your eyes are required.
Don’t forget to look at the patient as a whole. You just might prevent an adverse drug event (ADE)! For example, you receive orders for furosemide, insulin, and dextrose 50% for a patient. Your brain says, ooo, hyperkalemia! You confirm this by looking at the lab results, and you verify your new medication orders. Done, right?
But what if that patient is on lisinopril? Or losartan? Or spironolactone? Don’t those need some attention too?
You bet they do.
Same goes for when you’re adjusting vancomycin based on a newly resulted trough level. If you unexpectedly got back a trough of 35 mcg/mL and that serum creatinine has jumped up 50%, don’t just stop after you handle the vancomycin. Check out the other medications. Does anything need to be held? Do any doses need to be adjusted?
On the note of reviewing the patient as a whole, don’t forget to look for drug interactions - and look up any meds that you’re not sure about! Outside of well-known culprits like warfarin, there are so many sneaky things that can happen in the hospital. Those 2 doses of replacement magnesium oxide get put in as BID…which happens to match up perfectly with the PO ciprofloxacin BID.
Nay nay.
The list of CYP inducers and inhibitors might be a good “peripheral brain” candidate… perhaps.
When reviewing inpatient medication orders and comparing to the home medication list, see if there are any missing medications that might need to be continued. Even if a patient’s home medication or formulation isn’t available in your hospital, you can either try for a formulary substitution with a similar alternative, or you can start trying to arrange for the patient’s medication to be brought in from home.
It’s also good to refresh yourself on common acute conditions, so you know what kinds of orders to expect when you come across these (and vice-versa – you can guess the indications from the drug orders even when the physician hasn’t had time to input any documentation on the EMR yet). A non-exhaustive list is:
Hypoglycemia, hyperglycemic crises (DKA/HHS)
Hypokalemia and hyperkalemia
Sepsis
Tip #5: Take care of yourself
You need to be in tip-top condition – alert and awake - so you can avoid the pitfalls described above.
Make yourself a cup of coffee or tea when you need it most. Go for a quick walk around the hospital if you can manage it.
Bring a cosy cushion from home, so you can have a good rest during breaks.
Order in food from your favorite burger or pizza joint.
Having said all that, sometimes you just can’t predict what kind of patient cases you’ll encounter through the night...so gear up, just do it, and enjoy the ride!
