Welcome new grads! You’ve walked the walk, tossed your cap, and passed your boards, and now you’ve entered into the real world of pharmacy employment.

You, after graduation, trying to move to your new crib. In your sweet ride.

Aka: you probably feel a bit like you’re in the most never-ending syllabus orientation day ever, trying to keep track of all the on-boarding paperwork, employment requirements, and maybe residency project decisions...

Not to mention, hey, you’re now in charge of a full service of patients.

Including keeping up with that relentless order queue. Godspeed.

It’s probably around this point in your newborn career that you may be noticing a crucial hole in the last 4 years of your pharmacy education.

It’s entirely possible that you made it through every didactic course, every longitudinal project, every clinical rotation…without EVER verifying a single order!

And now you’ve got 75 of them waiting for you.

And, btw, 10 of them are needed NOW.

What the heck!?

How are you expected to function, and how could your beloved alma mater leave you hanging like this??

Well don’t worry, you’re not alone.

Most of us graduated without ever actually getting to hit the verify button.

You’re also not alone in learning. tl;dr is here to give you a leg up into the pharmacy saddle.

In this post, we're going to walk through a sample of the thought processes necessary when verifying inpatient orders.

As a side benefit of going through this process, you’ll also get an idea of how to work up patients.

If you're a P4 or a resident, you're going to need to get good and familiar with working up patients in an efficient manner.

So read this post, take what you want, roll it over, try it out, and then mold it into your own process that works for you.

Let’s get started.

The Pharmacist's Order Verification Process

You see an order for ceftriaxone STAT in the queue. Being a brave new employee, you decide not to cherry pick around the stat order and go for it. So you open the order, read that it’s ceftriaxone 1g q24h (sounds like a reasonable dose, right?), and poof, it’s verified, right?

Got that stat order done in a solid 20 seconds, #winning.

WRONG.

Take #2.

You open the ceftriaxone order. And pause. Yes, I know it’s a stat order, but for the love of Pete, let’s get it right.

So first… It’s time to be the pharmacy detective you were born to be. Or at least the one your teachers tried to shape you into the last few years.

Let's start with this. Who is your patient?

How old is your patient? Is this an 18 YOF or a 90 YOM?

Is the patient in the emergency department, or has he already been transferred to a floor bed? If so, does the assigned unit or provider team give you any clues as to why he is here?

Is he 45 kg or 145 kg?

Does he have any noted medication allergies, and has this information been updated this admission?

If he does have medication allergies, are any of them to pertinent antibiotics - penicillins or cephalosporins? If so, what was the recorded reaction - rash or shortness of breath?

This is for all you former (or, don't lie, current) Disney Channelers. (Image)

Soooo much information, and that’s literally just the patient information banner at the top of the screen.

Next, we need to know a little bit about what we’re treating with this ceftriaxone.

Head to the physician notes to do some reading.

Well drat. The patient was just admitted, and there’s no H&P in the computer yet. How are we supposed to know whether the drug and dose are appropriate if we can’t read the MD note?

Oooo… let’s look at microbiology orders! Our patient happens to have a pending urine culture.

But what if there wasn’t anything in the microbiology order section? What then?

Check the radiology - does the patient have a chest x-ray with opacities indicating infection? Lower extremity x-ray with findings of osteomyelitis? An order to do an LP?

Check the patient’s lab results - does he have a paracentesis fluid analysis listed? Is there a urinalysis available?

Long story short, you might have to play Sherlock Holmes in order to piece together what the provider’s rationale is for a particular drug and dose.

It’s your judgement and comfort with chart navigation when it comes to how long you feel you can spend sifting through the EMR (that's what us cool kids call the "Electronic Medical Record").

On the other hand, if it’s a stat order for an ICU patient and you see orders coming through for pressors, maybe you spend a wee bit less time detective-ing and go ahead and shoot a page to the team if clarification is needed.

But back to our patient, who has a pending urine culture.

Let's next take a look at the other medications the patient has ordered already. Ideally, (especially with a high alert medication like an antibiotic), that means actually looking at the MAR (and that's what us cool kids call the "Medication Administration Record").

Not just the list of medications on your initial patient screen…the MAR. The difference is crucial, because the MAR will actually tell you what the nurse has administered to the patient since the patient arrived at the hospital.

Does the patient have other antibiotics ordered? If so, is this ceftriaxone duplicative coverage or additive?

Has the patient already received antibiotics today? If so, what time was the last dose, and when would it make sense for the patient to need a subsequent dose?

If the patient received cefepime an hour ago, he probably doesn't need that ceftriaxone just yet. Alternatively, if all the patient had was a dose of cephalexin an hour ago and now he's showing signs of sepsis, we probably need to get that ceftriaxone infused ASAP.

At this point, we’ve done some good background work to determine who our patient is as well as why we’re using the ceftriaxone. It’s time to return to that stat order.

Happily, most pharmacy systems have prebuilt IV products, so you don’t usually have to worry about what fluid or volume the drug is being mixed in (This was always one of my biggest fears as a student. How does one keep up with all that compatibility info?! Computers, my friends, computers).

Of course, that database is dependent upon the efforts of your pharmacy IT department, so hopefully they’ve been able to keep your medication system up to date with all the drug/fluid shortages.

So we have ceftriaxone 1g in 100 mL of normal saline (a prebuilt orderable). The dose is 1g, route is IV, frequency is q24h, and infusion time is 30 minutes (also usually prebuilt, but you should always still assess). All of these facets match up with what we know about treating a urinary tract infection.

There is no renal dosing adjustment for ceftriaxone, so we don’t have to worry about assessing for that in this particular case.

Then we move on to schedule. Even if the order is stat, we should make sure we're scheduling this dose appropriately based on any prior antibiotic doses. So the date and time of first dose are set based on the MAR information gleaned earlier.

Next we need to make sure the dispense information is correct. Is this a dose that we’re making in the IV room because of shortages? Or is it a vial + fluid bag the nurse can pull from the dispensing cabinet on the floor without having to wait on it to come from pharmacy?

Whatever your facility’s policies, make sure you’re dispensing the right way to prevent delays in doses!

Finally, be sure to read any administration instructions either prebuilt into the order or manually typed in by the ordering provider.

You can learn LOADS by reading these order comments. How is naloxone administered again? Ohhhh we dilute the vial with this flush syringe and administer in increments…got it…
You need to make sure the comments are in line with what you know about the medication and the patient.
Depending on your institution’s policies, maybe there’s an administration instruction you would like to add to ensure safe administration. Should we contact the provider to ask for HR and BP hold parameters for that metoprolol?

Here's looking at you, pharmacist! (Image)

At this point, assuming all of this information is correct and appropriate for the ceftriaxone, you’re ready to verify!

Buuuuut that doesn’t necessarily mean you’re done.

You may want to contact the nurse to provide some tidbit of education. Maybe your patient has a listed allergy of rash to penicillin, and there are no records that he has ever tolerated a cephalosporin. It may be helpful to call the nurse to give her a heads up to monitor for a rash, especially during the first infusion.

Phew. All that for just one stat ceftriaxone order…!

And now there are 10 more orders in your queue that popped up while you were working on this one.

Welcome to pharmacy, peeps. You can do this.

A few pieces of extra advice.

1. You should feel comfortable, aka like you have done your due diligence to the fullest extent, before verifying an order.

If there’s something you’re not sure about, whether it’s drug, dose, indication, monitoring, allergies, whatEVER, please please please ask a colleague!

2. Pharmacy is absolutely a collaborative profession, and we all bounce questions off of each other constantly. You should feel free to do the same. Don’t feel like you have to prove you’re a master pharmacist from day 1. We all started somewhere, and it's a fair bet that we all learn something new every day.

3. On that note, you’re going to be slow when you start! News flash...we were all slow when we started. I remember spending 30 minutes staring at my first PRN acetaminophen order. I went through each piece of the order approximately 50 billion times, but you know what, that’s what it took for me to feel comfortable hitting that verify button. And that’s ok.

Granted, of course we don’t want you to always take that long! You’re going to grow and develop and get faster.

But if I was your patient, I’d take a slow, thorough pharmacist ANYDAY over a fast, reckless one. Start slowly, and you’ll naturally get increasingly comfortable.

4. Over time, you’ll build a sort of mental repository about what items you should check for various types of medication orders. We walked through a basic ceftriaxone order here, but you’ll take all of that drug knowledge you learned in school and turn it into mental checklists for a plethora of drugs.

What kind of monitoring should we do for furosemide? Metoprolol? Daptomycin? Which drugs require dosing adjustments? Check THAT information before verifying!

5. Use your references. I don’t care if you’ve looked up renal dosing of cefepime 3 times already in one shift while you’re training. If you can’t remember it yet, look it up again.

Better to do that than end up with toxicities the next day and a patient in jeopardy. You’ll eventually remember the information such that you won’t have to look up every piece. But until then - LOOK IT UP.

6. You’ll learn to deal with the gray areas of order verification. Unfortunately, there has to be some measure of trust in ordering providers, and we can’t always have things 100% pharmacy-happy.

For example, as far as whether a patient needs furosemide 10mg IV x1 versus 20mg IV x1? We're pharmacists. We're not necessarily looking at the patient. We're not seeing the edema in his legs or hearing the crackles in his lungs. So we're probably not the best judge of which dose is most appropriate.

However, we can alert the provider to watch his low BP or replete his electrolytes. Know what I mean?

7. Finally, medications get off schedule.

Q8h might actually turn out to be q5h this morning and q7h this evening.

Use your judgment to determine how to adjust schedules.

But realize that the real world doesn’t operate on perfect times (as much as our pharmacy OCD would like it to!).

Hopefully, this post gives you some food for thought about how to go about diving into the world of order verification. If you find yourself on autopilot at any point (and you will, trust me), take a moment of pause and STOP.

Consider if the patient on your screen was your mom or dad. Then go back to giving them the attention they deserve. Know you’re never alone, and with time, it will get easier!

Now go rock that orientation and take care of your patients, you pharmacist BOSS, you.

Fist bump puppy thinks you got it too. (Image)

How to Verify Medication Orders Like a Pharmacist Boss

The Pharmacist's Order Verification Process