AS A NEW PRACTITIONER at a 250-bed hospital, working the weekends can be intimidating. Fewer pharmacy staff work on weekends, and clinical and administrative support is only available via paging. The punctuality of a call back can vary widely.
On the weekends, you also receive many verbal orders and admissions from on-call physicians, a concern because increased error rates with verbal orders have been well documented.1 As an evening pharmacist, I often work two and half hours alone. Pharmacists must always be vigilant to ensure the best patient care, but the need to have heightened safeguards is even more important when you practice under low-staffing conditions.
Questioning a Verbal Order
Working in this environment builds your confidence, but the first year is difficult. Interventions can happen at any time. Late one Saturday night, I received a verbal order for “low-dose dopamine titrate to systolic blood pressure greater than 90 mm Hg” for a patient in the ICU.
Two blood cultures were also ordered by the same physician. I called the nurse to ascertain what was going on with the patient. The patient was hypotensive with mean arterial pressures less than 65 mm Hg and possible sepsis. Because new “Surviving Sepsis” guidelines2 indicate that norepinephrine was the vasopressor of choice, I wanted to ensure that the ordering physician had a specific reason for placing the patient on this particular regimen.
Interventions can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do.
I paged the physician and discussed with him the current guidelines that show dopamine had higher mortality and supraventricular and ventricular arrhythmias when compared to dopamine. Because the guidelines had just come out, he was unaware of the new recommendations and thanked me for calling this to his attention. He went on to give me a new verbal order to change the patient to norepinephrine.
I walked up to the ICU and wrote the verbal orders to discontinue the dopamine drip and start a norepinephrine drip. I also spoke with the patient’s nurse and another nurse on the floor about the current “Surviving Sepsis” guideline recommendations on vasopressors.
An Opportunity to Build Relationships
The extensive time that it takes new knowledge to disseminate is well-documented in the literature. (It typically takes about 17 years before it becomes routine practice). Pharmacists can ensure they are doing what’s best for the patient by staying as up-to-date as possible on new clinical guidelines and recommendations. Being on the sharp edge of new information on medication use—and helping to disseminate that information to other members of the health care team—is critical to providing safe and effective treatment.
These types of interventions are not atypical, but I believe that they can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do. It’s also important for new practitioners to develop confidence in discussing therapeutic changes with physicians. Interventions such as this one help to increase your rapport with practitioners, boost appreciation for a pharmacist’s role in patient care, and increase one’s own self-confidence in performing the critical duties of a pharmacist.
–By Bryan Pinckney White, Pharm.D., Staff Pharmacist, St. Francis Hospital, Columbus, GA
- Fijn R; Van den Bemt, P.M.L.A.; Chow, M.; De Blaey, C.J.; Jong‐Van den Berg, D.; & Brouwers, J.R.B.J. (2002). Hospital prescribing errors: Epidemiological assessment of predictors. British journal of clinical pharmacology, 53(3), 326-331.
- Dellinger, R.P.; Levy, M.; Rhodes, A.; Annane, D,; Gerlach, H.; Opal, S.M.; Moreno, R. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.