Your best intevention?

[Dred Pirate]

So much of this board is bashing retail (specifically CVS), debating the merits of a residency, and discussing student loans. So lets actually talk something related to our job. What is everybody's best / most influential intervention they made?
The one that sticks out to me is when we were working a "off and on" code of a guy going in and out of vfib. We shocked him like 12 times. EMS brought in his daily pill planer (no bottles) and I was going through them trying to see if anything in there could give us a clue (obviously he could not tell us and there was no family present). I saw dofetilide in there and suggested pushing 2 grams of mag. The MD said it didn't look like torsades - I replied, at this point will it hurt? MD said "Good point". We gave the mag, and finally he converted to NSR - took him to the cath lab, put in a IAD. The next day he wanted to go home, his only complaint was a the burns on his chest.

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[BidingMyTime]

Dred Pirate--that is definitely a great intervention. I can't think of anything off hand I've done that is super memorable. Other then this 1 intervention, which was so obvious I couldn't figure out why it hadn't already been done, a guy with diabetes who had been brought into the ER like 3 or 4 times because of hypoglycemia, and I suggested giving him an RX for glucagon.

 

[Dred Pirate]

Dred Pirate--that is definitely a great intervention. I can't think of anything off hand I've done that is super memorable. Other then this 1 intervention, which was so obvious I couldn't figure out why it hadn't already been done, a guy with diabetes who had been brought into the ER like 3 or 4 times because of hypoglycemia, and I suggested giving him an RX for glucagon.

interventions don't have to be big to be important - if giving the guy glucagon saves a ER visit or two - you just saved the health system $1-2 thousand - that paid your salary for a week. Something as simple as giving lacrilube to a paralyzed intubated patient can save their eye sight,

 

[y0ssarian87]

I'm not a pharmacist -- still a student. I volunteer at our university's HIV center, and we do weekly HIV testing in a Walgreens pharmacy in downtown Baltimore. A couple came in, and the woman wanted to get tested but the guy didn't. After talking to the woman, I found that they were engaged, and they were in a serodiscordant relationship. The guy was positive (undetectable VL), and the woman wasn't. They had been trying to conceive (thus unsafe sex), and she was trying to make sure she was still negative. I was able to refer her to our clinic to discuss whether PrEP was appropriate for her. She came back for follow up, and, from what I heard, began PrEP.

Nothing remarkable, but it felt good to have an impact as a student.

 

[dbarth101]

I volunteer at this homeless shelter (it counts for like our hours of outreach we have to do, so I guess technically not volunteering) that has a student clinic. We have like 5 med students 5 pharmacy students an attending physician (usually an ER resident from area) and a pharmacist that work it. Biggest drug we give out is probably Tylenol, but it is a good learning opportunity and good to work with the "team" to work up patients. Anyway, some people no showed and my friend who was the "pharmacy rep" asked if I could come and I did. Myself and two medical students were working up a patient while 3 med students were working up another patient. All the pharmacy really does is do a poor man's med-rec and discharge counseling. Anyway, guy had a broken ankle, but also had the beginning of what the med students thought was a sore on his foot. Homeless guy said it had been bothering him all week, but the ankle was his chief complaint. Had 0 PMH or familial history. After the entire workup we were waiting to present to the "attending", and then I suggested we do a glucose. The med students said verbatim, "That actually... isn't a terrible idea". (Thanks jerk ). Guy ended up having a blood glucose 6 hours since he had last eaten of 252. We shipped him off to the real ER, and the one med student girl just kept calling me "brilliant". Not a huge thing, but it felt good and I think that medical student will always know for her career that pharmacists are a good tool.

Edit: I'm still a student obviously

 

[El Trombopag]

My most memorable intervention was as a student on a rotation at the poison center. One of the chart reviews I was doing looked a lot like amatoxin poisoning -- it was mentioned as 'possible'. I called and asked the nurse to ask the patient where she was picking mushrooms. It was a significant question to me because I knew amatoxin-containing mushrooms [e.g. 'death caps'] had only rarely been reported in the area, and poisonings only a couple of times in the entire state [Galerina aside]. The degree of liver damage with no other abnormalities was strongly suggestive of a potent hepatotoxin [like the death cap, destroying angel, other Amanita spp.] I went to the park she named and, sure enough, after about 2 hours of hunting I found about a half-dozen Amanita phalloides fruitbodies. GPS locations were taken, the fruits were positively ID'd at the university, and the poison center made a public service announcement about the case. The patient was close to discharge by the time I found them, so it didn't really directly affect care/outcome. It did result in a publication which was cool

These were the offenders!

 

[Wheresmyaricept]

That time the cardiologist put a guy on metoprolol succinate for AFib and the GP put him on atenolol and was getting it filled at different pharmacies.

Kept complaining of passing out after standing up. Asked what meds he was on, called the cardiologist. D/c'd atenolol and doesn't pass out. So there's that.

 

[Rockinacoustic]

As much as I don't miss retail, a good intervention could really make your day. For me it was one of those days where you're feeling wild and instead of asking the robotic "do you have any questions about this medicine?" you just direct them down to the counseling area and lay it out for them about their medicine. Lo and behold you come to find out they broke out in hives last time they got penicillin. You call up the NP at the urgent care and she exclaims "I had no idea amoxicillin was cross-reactive with penicillin!". Five minutes later you hand the patient some Keflex and they smile and say "thank you doctor" like you're in some APhA student pharmacist video they showed you during first-year orientation.

Then you turn around and realize your pharmacist is still on the phone with insurance for a vacation override on that Vyvanse and it hits you- I shouldn't have signed that grad-intern offer.

 

[rph3664]

Probably my best retail intervention, because it resulted in the patient no longer coming to us, was exposing a drug-seeker to his latest doctor. I faxed (ca. 2000) his med profile to the doctor, who didn't believe me, and he called me back and said that guy wasn't going to be back at his office.

When the store manager got wind of it, he wasn't very happy because to him, any customer was OK as long as the money was green, no matter how many times we told him it doesn't work that way.

I don't remember the drug, but we had a wonky prescription from a local pediatrician, and the mom wasn't very happy that we were going to have to call him and have her come back later. However, when she returned, she apologized for snapping at us, because the doctor told her that had we filled the prescription and she gave it as written, it might have killed her child.

 

[Digsbe]

Still a student, but I made several interventions on my first APPE. I guess the biggest was a heart failure patient with diabetes, hypertension, and the typical stuff along with chronic kidney disease receiving Invokana with a GFR of 28 as well as not being on an ACE/ARB for their HTN, CHF, and CKD. They were only using a beta blocker and the HTN was not controlled (although they were prob dual purposing it for the CHF). When the cardiologist saw them all they did was change their metoprolol to carvedilol and after that I put the interventions in to my preceptor. I recommended putting them on an ACE/ARB and D/C the Invokana due to the CKD and decreased kidney clearance. That was probably the most "complex" intervention I ever made, idk if it was accepted though since it was literally near my last day of the rotation.

 

[trailerpark]

I lowered a dose of 20 mg simvastatin to 10 mg for a patient on diltiazem.

 

[sosoo]

a customer comes with 2 scripts, one for proair and another for cough syrup with codeine. i figure the codeine cough syrup wasn't more important than his breathing, so i only dispense proair. #caution.

 

[owlegrad]

I seem to vaguely recall that I once made interventions. It's all so hazy now. Did I really catch a flagyl/coumadin interaction or is that my imagination?

 

[sosoo]

I lowered a dose of 20 mg simvastatin to 10 mg for a patient on diltiazem.

did u follow up with his cholesterol level before and after?

 

[ancienbon]

I can remember a few
viagra and isosorbide. Pat said forget isorsorbide
ibuprofen from dentist and warfarin

MD sent clomipramine istead of clomid

 

[WVUPharm2007]

http://forums.studentdoctor.net/threads/vivitrol-and-legit-acute-pain.668545/

 

[bacillus1]

One time I prevented the team from prescribing lisinopril to a pt with a Lotrel allergy (angioedema), also I recall reminding the team to order PO vanc for discharge for a patient with C. diff for whom they forgot to order it. Otherwise not too many "Earth-shattering" interventions, just your usual stuff. Today I had to page the psych resident twice for 2 different patients because she was starting PRN ibuprofen on top of standing NSAIDs that were at or near their max doses. Also talked a surgeon (forget which variety) out of using synergy gent for an abscess in an end of life pt with CrCl of 13...we went with linezolid instead (VRE resistant to pretty much everything else) and helped the ID team dose daptomycin, along with a bunch of warfarin recs. That's pretty much the typical amount of recs I make in a day, aside from the fact that I didn't do any discharge med recs since I wasn't doing that this weekend.

 

[Deja]

don't remember much, everything is like a haze working retail, most common ones are catching an allergy for meds about to be dispensed, or duplicate therapy by different doctors... or that one time woman asked where the OTC water pill was, instead of just pointing it to where it was, I asked why and found out it's cause her legs were swollen, I referred her to the nearest hospital, she came back thanking me cause there was indeed a problem with her heart...

 

[sakigt]

Nothing too crazy. Saved a life (for organ donation) when I suggested the amio.

The best ones are the ones someone would usually routinely miss. I flagged a new fentanyl patch for uncontrolled pain. I did some digging and the pt should have barely been on 25mcg and he wrote for 50. I convinced him to change to 25 (I hardly EVER call oncology docs for med changes.....who would??) and the next day they d/c'd that for low dose oxycontin because the lady passed out.

I saw a metoprolol tartrate daily come through....figured it was a mistake and should have been XR. I did some digging and found the original script was for metoprolol 25 daily....hmmm....asked the pt for where she filled the med....she actually had the bottle. Filled as metoprolol 25 (no salt)......hmmmm. Did an actual pill ID, it was tartrate. Patient was being admitted for cardiac workup because her blood pressure would spike in the evenings........ I told the hospitalist and the cardiologist had her out within hours with instructions to take it twice a day. I wonder how much $$$ I saved with that one.

 

[BidingMyTime]

This is a really cool thread. I'll add, there have been several times, 2 of which would have likely been fatal, intervened in potential fentanyl patch overdoses. One was a doctor who wanted to start someone on 225mcg of fentanyl--yes, the patient had quite an extensive narcotic usage, but not that much! I talked to the doctor, he really didn't understand how he made such a conversion error, I recommend starting on 50mcg, he wanted 75mcg and I that would be OK (the conversion was kind of in the middle, I wanted to round down, the doctor wanted to round up.....either way, it was much more acceptable than 225.) This one was retail,a pediatric post-op patient, she was still having pain after 2 days on T3, so the doctor want to put her on 25mcg fentayl. Unbelievably, the doctor refused to change. I talked to the doctor personally, and any other option I mentioned (say Percocet), the doctor said he was "not comfortable prescribing that"....but he was confortable putting a narcotic naïve patient on a fentanyl patch, esp since this was an outpatient with no monitoring whatsoever??? I gave the prescription back to the parent, I was pretty blunt and told the parent that I thought the dose was potentially fatal, that I would not fill the dose & I highly recommended that she not fill it anywhere else. The parent was quite livid at the doctor, and said the child's pain was tolerable, and had just asked the doctor if it was possible to get something a little stronger since the child was still having pain. The other changes I've recommended have not been as melodramatic, but involved a doctor wanting to start a patient on 75 or 100mcg when 50 or 75mcg was more reasonable.

I am amazed at all the fentanyl patch dosing errors I am still seeing, even though the literature has been full of deaths, and the FDA has warned about inappropriate prescribing of fentanyl patches for many years.

 

[Carboxide]

Hmm, one good one - we added a new drug to formulary that was dosed quite differently from our previous formulation. That hadn't been communicated to staff. I realized we were overdosing pts by 3 doses a day and costing the hospital hundreds (if not thousands) in the process.

 

[Dred Pirate]

Hmm, one good one - we added a new drug to formulary that was dosed quite differently from our previous formulation. That hadn't been communicated to staff. I realized we were overdosing pts by 3 doses a day and costing the hospital hundreds (if not thousands) in the process.

what drug?

 

[Dred Pirate]

I had a "I can't believe they couldn't figure it out moment". I was working in the ED and I got a call from a frantic RN saying her and the MD couldn't figure out how to turn off an unresponsive patient's insulin pump and his BS was 30. I walked into the room and just pulled out the catheter - bam - done. They all looked at me and they started laughing because they realized how stupid they seemed.

 

[rph3664]

I can remember a few
viagra and isosorbide. Pat said forget isorsorbide

The first time I was involved in a Viagra/nitroglycerin intervention, the man was FURIOUS and kept hollering that we were probably the type who would take candy away from a baby. No, dude, we possibly saved your life. I later told the pharmacist who was more hands-on in this than I was that chances are, the Viagra probably wouldn't have worked anyway.

 

[rph3664]

Hmm, one good one - we added a new drug to formulary that was dosed quite differently from our previous formulation. That hadn't been communicated to staff. I realized we were overdosing pts by 3 doses a day and costing the hospital hundreds (if not thousands) in the process.

What drug was it?

 

[rph3664]

Also talked a surgeon (forget which variety) out of using synergy gent for an abscess in an end of life pt with CrCl of 13...we went with linezolid instead (VRE resistant to pretty much everything else) and helped the ID team dose daptomycin, along with a bunch of warfarin recs. That's pretty much the typical amount of recs I make in a day, aside from the fact that I didn't do any discharge med recs since I wasn't doing that this weekend.

Why did they order such aggressive ABX therapy on an end-of-life patient? Did the family insist on it?

 

[Carboxide]

What drug was it?

Posaconazole. Liquid is TID-QID depending on ppx vs tx. Tablet is 300 mg BID for 1 day, then daily onwards no matter what the indication.

 

[bacillus1]

Why did they order such aggressive ABX therapy on an end-of-life patient? Did the family insist on it?

These were the only 2 ABX that the pt was sensitive to. Seems like the pt really wanted his life prolonged by a bit. I forget what exactly what the circumstances were, but I believe it was an issue of being with family longer.

 

[Farcus]

some recent ones,

spoke to pulmonigist about why he's bridging pradaxa 150 q12h w/ lovenox q12h tx dose for past two days, he told me it was the studies -_-'' though i'll handle it to him the RECOVER trial does say 5 days of lovenox, but just not together lol.

mrsa bacteremia, abd infection (don't remember) w/hx multiple revision of some gi processs, ID put zyvox from vanco due renal bad shape, spoke to ID to switch dapto if repeat bcx they got today was +cx again they said they'll consider it, i come work today, on daptomycin

mvr valve no other hx other than DM and anxiety. admit sz x3 unexplained, spoke primary about sz because he also consulted us to dose warfarin. told him pt on zyvox outpt and apparently on 100mg zolort could be serotonin syndrome as recent onset of sz, unconscious, labile bp/hr and he said was good idea but just defer to neuro, couple days later pt daughter was a PA who say pt was also on wellbutyrin 75mg. told neuro, but he keep insisting it was because didn't take their schedule lorazpam for a week that the daughter told him but at that point was a clear case of multifactorial DDI and drug compliance issue.

vit-k 10mg iv x1, then x1 tomorrow, x1 day after that for suspected vit-k defieiency when vit-k highest was 1.5 and day order written was 1.2, with no confirmed cirrhosis though some centrilobular process going on per path though and abnormal lft probably congestive hepatopathy 2/2 from ESHD as was admit for heart+kidney transplant pending and so it was a really big mess with a lot of service and pain in the ass to find out who to call. Finally convinced the oncall guy to do just 5mg iv x1 with a INR of 1.2 that day!!! he wouldn't budge anymore and to get INR in couple hr and they can reassess day after to see if it made any damn difference and to reassess if need to give this pt 30mg of vit-k. no varices/mild thrombocytopenic. I'm off so didn't really f/u on the case but really out of ordinary.

my favorite one and probably life saving with i saw why was really old on xarelto 20+plavix+asa when their admit was s/p fall from nh w/ admit hbg 5.9???!!!! lol received two day worth until i caught it but surprisingly hbg went up to 6.1. These MD just reorder meds home meds without ever looking at the god damn drugs. interestingly was the pt went for scope that day too??!! but they left out alive

my favorite one that I witness and observed was by my preceptor awhile back was simply starting steroid in a likely CIRIC patient w/ max dopa/levo/vaso with a SVR initially of 600-700 or so. After steroid half the drip rate was reduced, map improved and I think a week later was out of CVICU. But my preceptor is really good, really really damn good.

i work in a community hospital so these sort of crap happens, which from academic center i was trained would be unheard of generally

great thread btw, i feel like this is a good place to learn from other pharmacist's experience. One hospital i was in had quarterly report of serious intervention that are brought up to medical executive committee for review and i felt i also learned something from those, hopefully more people contribute really good ones.

 

[ExpressMaiL]

Convincing someone to go Android over iPhone.

 

[npage148]

I am amazed at all the fentanyl patch dosing errors I am still seeing, even though the literature has been full of deaths, and the FDA has warned about inappropriate prescribing of fentanyl patches for many years.

Similar thing with me last month. Dr wanted to start an opiate naive pt on fentanyl 25 for some non-significant pain. I called and his reason was that it would be easier for her to not have to take a pill qid. I did the whole fentanyl speach and he was like ok we can start with 12.5. I was like no, I'll fax you the Rems, the 5 letters to prescribers, and the black box warning to you and you can read it and if you still want to discuss is give me a call back. He never called back and we managed to not kill this lady

 

[CUpharmD2013]

A bunch that I can't remember right now, but the one that comes to mind was a dexamethasone IV that was made with dexmedetomidine. One of the techs had filled the dexamethasone bin with dexmedetomidine by accident. Tech making the IV didn't even check the label. Caught it before it went to the floor.

 

[Dred Pirate]

A bunch that I can't remember right now, but the one that comes to mind was a dexamethasone IV that was made with dexmedetomidine. One of the techs had filled the dexamethasone bin with dexmedetomidine by accident. Tech making the IV didn't even check the label. Caught it before it went to the floor.

ya - that could have gotten bad quick

 

[npage148]

Similar thing with me last month. Dr wanted to start an opiate naive pt on fentanyl 25 for some non-significant pain. I called and his reason was that it would be easier for her to not have to take a pill qid. I did the whole fentanyl speach and he was like ok we can start with 12.5. I was like no, I'll fax you the Rems, the 5 letters to prescribers, and the black box warning to you and you can read it and if you still want to discuss is give me a call back. He never called back and we managed to not kill this lady

Another one this weekend! Wanted to start a woman stable on T&C #4 1 tid on the 12mcg patch. Got snippy because he's been doing it for years, my concern was "interesting" , asked how he can "override" the contraindication and refusal to fill, and took my name down for later. He called back with a much nicer tone asking for some prescribing info, I'm guessing he did some googling. I guess I see why fentanyl hurts so many people...

 

[Dred Pirate]

Another one this weekend! Wanted to start a woman stable on T&C #4 1 tid on the 12mcg patch. Got snippy because he's been doing it for years, my concern was "interesting" , asked how he can "override" the contraindication and refusal to fill, and took my name down for later. He called back with a much nicer tone asking for some prescribing info, I'm guessing he did some googling. I guess I see why fentanyl hurts so many people...

I am more surprised there is a doc actually ordering T#4's still

 

[GoldfishPharmD]

So didn't know where to put this and didn't want to start a new thread:

So, what are you guy's thought on being overly cautious. I'm in the training process today at my new hospital and we each went up in front of our small group to verify orders and try to catch common things that would need to be fixed due to the computer system (the logistical stuff). Anyways, my hospital has a potassium protocol and I was verifying some. It was for 20 mEq and I really hate to blindly verifying stuff without looking at K, SCr, etc. At the end of the day, the other pharmacists were kinda like they wouldn't bother to check electrolytes for a one time 20 mEq KCl or bother looking at mag levels for IV mag, which that statement made me feel a bit self conscious because I would (still going to). 1) I've worked with medical residents doing all the orders and come across so many easy mistakes, 2) I like to get to know the patient - is this a common problem for this patient, are they on meds that could make their K low/high, are we giving K to someone that doesn't really need it, how good/bad is their renal function, etc. For mag, yeah it's benign but sometimes I feel like it's unnecessary and we had a IV mag shortage that was reserved for patient's with cardiovascular issues, so I guess I'm conditioned to check how bad a patient's mag level is and if they can just get oral replacement instead. The vast majority of my patients last year were renal transplant patients or dialysis patients, so maybe I'm just more sensitive to electrolytes. Blah.

 

[Dred Pirate]

So didn't know where to put this and didn't want to start a new thread:

So, what are you guy's thought on being overly cautious. I'm in the training process today at my new hospital and we each went up in front of our small group to verify orders and try to catch common things that would need to be fixed due to the computer system (the logistical stuff). Anyways, my hospital has a potassium protocol and I was verifying some. It was for 20 mEq and I really hate to blindly verifying stuff without looking at K, SCr, etc. At the end of the day, the other pharmacists were kinda like they wouldn't bother to check electrolytes for a one time 20 mEq KCl or bother looking at mag levels for IV mag, which that statement made me feel a bit self conscious because I would (still going to). 1) I've worked with medical residents doing all the orders and come across so many easy mistakes, 2) I like to get to know the patient - is this a common problem for this patient, are they on meds that could make their K low/high, are we giving K to someone that doesn't really need it, how good/bad is their renal function, etc. For mag, yeah it's benign but sometimes I feel like it's unnecessary and we had a IV mag shortage that was reserved for patient's with cardiovascular issues, so I guess I'm conditioned to check how bad a patient's mag level is and if they can just get oral replacement instead. The vast majority of my patients last year were renal transplant patients or dialysis patients, so maybe I'm just more sensitive to electrolytes. Blah.

with our Emar the lab value shows up on the same screen when we get an order for KCl or Mag, so it take a whopping 3 seconds to look at the value. In our old EMar we had to go to the lab section and pull up the values. Either way, I check them every time. I caught so many errors even with our pot and mag protocols. Check it, you will catch errors.

 

[GoldfishPharmD]

with our Emar the lab value shows up on the same screen when we get an order for KCl or Mag, so it take a whopping 3 seconds to look at the value. In our old EMar we had to go to the lab section and pull up the values. Either way, I check them every time. I caught so many errors even with our pot and mag protocols. Check it, you will catch errors.

Yeah, that's what we had when I was a PGY2. It was nice cause all the labs were right there for you. In this computer system, you have to pull up their EMR and look at lab values which is just extra steps. That's how I feel. You never know if someone accidentally ordered electrolytes for the wrong patient, etc. That statement just rubbed me the wrong way. I'm pretty quick with verifications. We had a 30 minute goal to get orders verified (unlaced they needed clarification) last year and I would say 90% of orders were verified in that time range. I just will always double check something before verifying when I'm the one responsible for my patients.

 

[Carboxide]

So didn't know where to put this and didn't want to start a new thread:

So, what are you guy's thought on being overly cautious. I'm in the training process today at my new hospital and we each went up in front of our small group to verify orders and try to catch common things that would need to be fixed due to the computer system (the logistical stuff). Anyways, my hospital has a potassium protocol and I was verifying some. It was for 20 mEq and I really hate to blindly verifying stuff without looking at K, SCr, etc. At the end of the day, the other pharmacists were kinda like they wouldn't bother to check electrolytes for a one time 20 mEq KCl or bother looking at mag levels for IV mag, which that statement made me feel a bit self conscious because I would (still going to). 1) I've worked with medical residents doing all the orders and come across so many easy mistakes, 2) I like to get to know the patient - is this a common problem for this patient, are they on meds that could make their K low/high, are we giving K to someone that doesn't really need it, how good/bad is their renal function, etc. For mag, yeah it's benign but sometimes I feel like it's unnecessary and we had a IV mag shortage that was reserved for patient's with cardiovascular issues, so I guess I'm conditioned to check how bad a patient's mag level is and if they can just get oral replacement instead. The vast majority of my patients last year were renal transplant patients or dialysis patients, so maybe I'm just more sensitive to electrolytes. Blah.

I used to look at everyone and now I do only if the dose is unusual or they're getting a second/duplicate order entered later, because I rarely found a problem that was actually worth calling on. In fact, I don't think I ever found a problem that I could strongly back up my concern. The reasons I don't really look are:

-Low dose electrolytes are unlikely to cause harm. 20 meq KCl is not going to kill anyone and I've never seen it ordered on a pt with hyperkalemia. Doesn't mean it wouldn't happen, but when you're verifying 600 orders a shift, you do what you can do. I spend a lot more time on higher risk drugs.
-With the exception of K+, there is no clear dosing guidelines for electrolytes. Mg = 1.7? You wanna give 4 grams? We don't have any data saying that it's going to raise your Mg a certain level and it could be dangerous, so what am I going to say when they call? "Well I can't say it is going to be bad but it kinda might be and I have this feeling that it might be higher than necessary..." now that is a waste of time.
-Unless a patient is a brand new start on a high dose med that causes electrolyte abnormalities, the use of lisinopril with a KCl dose is not going to be an issue. The patient is stabilized on that dose. They are not going to have a massive increase in potassium from a small dose change or continuation of a previous dose of lisinopril.
-Honestly, you can't 'get to know' every order you verify for every patient. Again - 600 orders a day here. Sometimes more. It's unreasonable to ask that of people.

 

[GoldfishPharmD]

I used to look at everyone and now I do only if the dose is unusual or they're getting a second/duplicate order entered later, because I rarely found a problem that was actually worth calling on. In fact, I don't think I ever found a problem that I could strongly back up my concern. The reasons I don't really look are:

-Low dose electrolytes are unlikely to cause harm. 20 meq KCl is not going to kill anyone and I've never seen it ordered on a pt with hyperkalemia. Doesn't mean it wouldn't happen, but when you're verifying 600 orders a shift, you do what you can do. I spend a lot more time on higher risk drugs.
-With the exception of K+, there is no clear dosing guidelines for electrolytes. Mg = 1.7? You wanna give 4 grams? We don't have any data saying that it's going to raise your Mg a certain level and it could be dangerous, so what am I going to say when they call? "Well I can't say it is going to be bad but it kinda might be and I have this feeling that it might be higher than necessary..." now that is a waste of time.
-Unless a patient is a brand new start on a high dose med that causes electrolyte abnormalities, the use of lisinopril with a KCl dose is not going to be an issue. The patient is stabilized on that dose. They are not going to have a massive increase in potassium from a small dose change or continuation of a previous dose of lisinopril.
-Honestly, you can't 'get to know' every order you verify for every patient. Again - 600 orders a day here. Sometimes more. It's unreasonable to ask that of people.

Yeah but our situations are completely different. I can understand if you're verifying a ton of orders that are coming through. When I was a PGY2, the most patients I had at one time was around 30. It was a pain to get in early in the mornings and review each patient, but I would even if it was just a quick glance at why they were admitted and then looking at all their meds to ensure they were dosed correctly/indicated. I won't be verifying 600 orders a day (thankfully). I'll be assigned to a specific patient population, most likely less than 30 a day, so I should have the time to get to know my patients well and make sure that all orders are appropriate. For mag, the only time I've ever called about it was due to the shortage and my hospital requiring IV only for our cardiovascular patients so I told that resident to use oral instead.

 

[Dred Pirate]

Yeah but our situations are completely different. I can understand if you're verifying a ton of orders that are coming through. When I was a PGY2, the most patients I had at one time was around 30. It was a pain to get in early in the mornings and review each patient, but I would even if it was just a quick glance at why they were admitted and then looking at all their meds to ensure they were dosed correctly/indicated. I won't be verifying 600 orders a day (thankfully). I'll be assigned to a specific patient population, most likely less than 30 a day, so I should have the time to get to know my patients well and make sure that all orders are appropriate. For mag, the only time I've ever called about it was due to the shortage and my hospital requiring IV only for our cardiovascular patients so I told that resident to use oral instead.

for me it is following the protocol - if a RN makes a mistake, we need to educate them, now that being said, giving somebody 20 vs 40 meq is likely going to cause ZERO harm, but the education is an important thing. This may be a small mistake, but maybe (I am thinking pie in the sky) that it makes them think they have to be more careful and can avoid making a bigger mistake in the future?

With EPIC it solves this problem, the lab shows right up next to it - it literally only takes 4 more seconds.

 

[Carboxide]

Yeah but our situations are completely different. I can understand if you're verifying a ton of orders that are coming through. When I was a PGY2, the most patients I had at one time was around 30. It was a pain to get in early in the mornings and review each patient, but I would even if it was just a quick glance at why they were admitted and then looking at all their meds to ensure they were dosed correctly/indicated. I won't be verifying 600 orders a day (thankfully). I'll be assigned to a specific patient population, most likely less than 30 a day, so I should have the time to get to know my patients well and make sure that all orders are appropriate. For mag, the only time I've ever called about it was due to the shortage and my hospital requiring IV only for our cardiovascular patients so I told that resident to use oral instead.

Oh yeah, sorry, didn't catch that in your original post that you are on a unit. Yes, I would definitely do a lot more checking if I was assigned to a specific unit and had minimal patient load.

 

[sakigt]

The only K Ive stopped was a home med restarted when the admitting diagnosis was Hyperkalemia