Verifying Medication Questions?

[wsbkp08]

Hi, hospital staff pharmacist here and I want to ask you guys few questions!
I am seeing many curve balls as I am verifying the orders.

If the frequency is different that what it says on Micromedex, but still under max dose would you guys verify? I got a clonidine order that is 0.1mg tid for blood pressure. I checked Micromedex and it says it's usually given BID (but max is 2.4mg/day)
I have numerous order sets like these. clonidine tid(?) lopressor 12.5 bid, lasix 80mg bid IV ?!

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[trailerpark]

What's wrong with Lopressor 12.5 mg BID?


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[Sparda29]

Hi, hospital staff pharmacist here and I want to ask you guys few questions!
I am seeing many curve balls as I am verifying the orders.

If the frequency is different that what it says on Micromedex, but still under max dose would you guys verify? I got a clonidine order that is 0.1mg tid for blood pressure. I checked Micromedex and it says it's usually given BID (but max is 2.4mg/day)
I have numerous order sets like these. clonidine tid(?) lopressor 12.5 bid, lasix 80mg bid IV ?!

All of those orders are fine.

 

[CountBy5s]

Hi, hospital staff pharmacist here and I want to ask you guys few questions!
I am seeing many curve balls as I am verifying the orders.

If the frequency is different that what it says on Micromedex, but still under max dose would you guys verify? I got a clonidine order that is 0.1mg tid for blood pressure. I checked Micromedex and it says it's usually given BID (but max is 2.4mg/day)
I have numerous order sets like these. clonidine tid(?) lopressor 12.5 bid, lasix 80mg bid IV ?!

Really? These are pretty normal orders.

 

[bacillus1]

Side question: do all of your hospitals have differing admin times for BID vs. Q12H as well as TID vs. Q8H. Here, TID is 1000-1400-1800 so clonidine 0.1mg TID would actually be incorrect...Quite a common mistake that providers make, and the staff pharmacists often forget to correct it.

Otherwise, yes, those are all normal orders. You'll get the hang of it with practice. Also, metoprolol IR twice daily is the most standard schedule for this...not sure why the confusion on this one.

 

[Serenade_Dream<3]

those orders make sense to me too, one indicator I use after looking at the dosing and the adjustments needed from the references is the PK/PD. Generally clonidines duration is marked as 6-10 hours so BID-TID dosing make sense with this in mind. Good luck on staffing ;D

 

[stark3]

Just wondering... How long have you been working hospital? These are quite normal tbh

 

[Niosh]

Side question: do all of your hospitals have differing admin times for BID vs. Q12H as well as TID vs. Q8H.

Most of our BID vs Q12H are different, but we do have a "Q12H standard times" that is essentially the same as our BID. Regular Q12H or Q8H for us means give the first dose now and then every 12/8 hours from now. All our BID, TID, QID dosing is while the typical patient would be awake, nothing at 0200 like a Q8H might get you.

 

[gwarm01]

You'll see a lot of orders that don't fit quite into the recommendations from various dosing sources. Just ask yourself if it makes sense, is there a reason why we might be doing it this way? You'll save yourself a lot of headaches and your doctors will be happy that you aren't constantly calling them over silly issues.

A lot of new pharmacists tend to be rigid and have trouble breaking away from the school mindset where you are either right or wrong. Just remember that medicine is as much art as it is science. It's living and constantly changing. The dosing recommendations from Lexicomp came about from both studying the drug and clinical practice. The oddball order you see today may just end up being the golden standard of tomorrow.

 

[bacillus1]

Most of our BID vs Q12H are different, but we do have a "Q12H standard times" that is essentially the same as our BID. Regular Q12H or Q8H for us means give the first dose now and then every 12/8 hours from now. All our BID, TID, QID dosing is while the typical patient would be awake, nothing at 0200 like a Q8H might get you.

Wow, and the nurses agree to do that (Q8H starting now then Q8H after), meaning that they might pass meds every hour if all their patients have different admin times? Interesting. Also probably not that great from a delirium standpoint...just wanted to see how other hospitals handle admin times. Sorry to derail thread.

 

[wsbkp08]

Side question: do all of your hospitals have differing admin times for BID vs. Q12H as well as TID vs. Q8H. Here, TID is 1000-1400-1800 so clonidine 0.1mg TID would actually be incorrect...Quite a common mistake that providers make, and the staff pharmacists often forget to correct it.
Otherwise, yes, those are all normal orders. You'll get the hang of it with practice. Also, metoprolol IR twice daily is the most standard schedule for this...not sure why the confusion on this one.

I think you can do both ways like standard sets something like 6 12 18... or change the time to 6hr after the time that i verify. I feel so stupid but why tid at those times that you put (10-14-18) would be incorrect?
nahh I just wanted throw out as an example bc micromedex only listed like 25mg not 12.5mg
I still verified bc it made sense, but I was trying to give an example where it's doesn't 100% match with micromedex

Just wondering... How long have you been working hospital? These are quite normal tbh

I got a job in January (had to wait extra longer b/c I had to move...). I shadowed a pharmacist for about good 2 weeks and I've started to work by myself last week.
Yea the orders do not alarm me like crazy but they are just not straight from the micromedex so wanted to throw it out there

You'll see a lot of orders that don't fit quite into the recommendations from various dosing sources. Just ask yourself if it makes sense, is there a reason why we might be doing it this way? You'll save yourself a lot of headaches and your doctors will be happy that you aren't constantly calling them over silly issues.

A lot of new pharmacists tend to be rigid and have trouble breaking away from the school mindset where you are either right or wrong. Just remember that medicine is as much art as it is science. It's living and constantly changing. The dosing recommendations from Lexicomp came about from both studying the drug and clinical practice. The oddball order you see today may just end up being the golden standard of tomorrow.

Thank you! 2 cents that I needed!

 

[Sparda29]

I think you can do both ways like standard sets something like 6 12 18... or change the time to 6hr after the time that i verify. I feel so stupid but why tid at those times that you put (10-14-18) would be incorrect?
nahh I just wanted throw out as an example bc micromedex only listed like 25mg not 12.5mg
I still verified bc it made sense, but I was trying to give an example where it's doesn't 100% match with micromedex


I got a job in January (had to wait extra longer b/c I had to move...). I shadowed a pharmacist for about good 2 weeks and I've started to work by myself last week.
Yea the orders do not alarm me like crazy but they are just not straight from the micromedex so wanted to throw it out there


Thank you! 2 cents that I needed!

Don't be "that" pharmacist who checks Lexi-Comp or Micromedex for everything. It's something that annoys me a lot about new pharmacists.

 

[CetiAlphaFive]

Hi, hospital staff pharmacist here and I want to ask you guys few questions!
I am seeing many curve balls as I am verifying the orders.

If the frequency is different that what it says on Micromedex, but still under max dose would you guys verify? I got a clonidine order that is 0.1mg tid for blood pressure. I checked Micromedex and it says it's usually given BID (but max is 2.4mg/day)
I have numerous order sets like these. clonidine tid(?) lopressor 12.5 bid, lasix 80mg bid IV ?!

I couldn't even get a call back for a hospital job when I was leaving Target and this guy's stumbling on P1 internship stuff. LOL

 

[bacillus1]

I think you can do both ways like standard sets something like 6 12 18... or change the time to 6hr after the time that i verify. I feel so stupid but why tid at those times that you put (10-14-18) would be incorrect?

If you space clonidine only 4 hours apart and give 3 doses in a day, then you get no clonidine the other 16 hours of the day, and you have risk of hypotension when the doses are "stacked" and hypertension when the patient is not receiving the drug for such a long time. Really, that dosing schedule is mainly appropriate for immediate release isosorbide and diuretics. Wouldn't make too much of a fuss about it with topicals and eye drops or long-acting things like amiodarone, since no need to wake patient up early for those. However, most TID drugs for blood pressure not previously mentioned should generally be evenly spread apart.

 

[wsbkp08]

Don't be "that" pharmacist who checks Lexi-Comp or Micromedex for everything. It's something that annoys me a lot about new pharmacists.

Give me a break lol it has been a month!

I couldn't even get a call back for a hospital job when I was leaving Target and this guy's stumbling on P1 internship stuff. LOL

lol.. haha hey man when I was first getting trained the pharmacist was like showing me all these videos about medication safety and patient dying bc of pharmacists' mistakes. It can drive you nuts
where are you located? Im in southern nj with border line of phily/nj area. I saw few hospital pharmacist positions opening up. Get a nj license or phily's (after internship hours)

If you space clonidine only 4 hours apart and give 3 doses in a day, then you get no clonidine the other 16 hours of the day, and you have risk of hypotension when the doses are "stacked" and hypertension when the patient is not receiving the drug for such a long time. Really, that dosing schedule is mainly appropriate for immediate release isosorbide and diuretics. Wouldn't make too much of a fuss about it with topicals and eye drops or long-acting things like amiodarone, since no need to wake patient up early for those. However, most TID drugs for blood pressure should generally be evenly spread apart.

Thanks a bunch man. It was very clear. You are my preceptor from now on lol
How did I not learn this in pharmacy school..? Maybe I did... lol

 

[bacillus1]

Give me a break lol it has been a month!


lol.. haha hey man when I was first getting trained the pharmacist was like showing me all these videos about medication safety and patient dying bc of pharmacists' mistakes. It can drive you nuts
where are you located? Im in southern nj with border line of phily/nj area. I saw few hospital pharmacist positions opening up. Get a nj license or phily's (after internship hours)


Thanks a bunch man. It was very clear. You are my preceptor from now on lol
How did I not learn this in pharmacy school..? Maybe I did... lol

It's not something you learn in school, it's using logic. As far as Philly, any clinical positions? OK with clinical coordinator as well. I have a PA license.

 

[wsbkp08]

It's not something you learn in school, it's using logic. As far as Philly, any clinical positions? OK with clinical coordinator as well. I have a PA license.

oh lol. man now I'm a person without logic... I just wanted a clear explanation man
I don't know about Philly area b/c I actually don't like to commute to Philly. Rush hours are real bad and I had enough from commuting to school. I just stayed in Southern Jersey area
Indeed it man. I haven't been to indeed since I got hired.
Few jobs should be opened.

 

[CetiAlphaFive]

oh lol. man now I'm a person without logic... I just wanted a clear explanation man
I don't know about Philly area b/c I actually don't like to commute to Philly. Rush hours are real bad and I had enough from commuting to school. I just stayed in Southern Jersey area
Indeed it man. I haven't been to indeed since I got hired.
Few jobs should be opened.

 

[farmadiazepine]

You need to work in retail, and then all of this stuff will not even faze you. I see clonidine Q6H, metoprolol tartrate QD, lisinopril BID, enalapril QD on the regular.

 

[Ackj]

You need to work in retail, and then all of this stuff will not even faze you. I see clonidine Q6H, metoprolol tartrate QD, lisinopril BID, enalapril QD on the regular.

I remember reading some study that Lisinopril bid was better than qd now. But I agree, you see a ton of wonky stuff that's not wrong enough to worry.

 

[ancienbon]

The op got to be kidding. You want to call on those orders? You would not survive retail.

 

[Sine Cura]

It doesn't have to be "right" as long as it's not wrong.

 

[gwarm01]

It doesn't have to be "right" as long as it's not wrong.

These wise words will save you such much trouble.

 

[BidingMyTime]

Yeah, if it's not going to harm the patient, then verify it, even if it seems silly. Remember the placebo effect is strong, and if someone feels better taking their QD medicine as 1/2 dose BID, then good for them.

Side question: do all of your hospitals have differing admin times for BID vs. Q12H as well as TID vs. Q8H. Here, TID is 1000-1400-1800 so clonidine 0.1mg TID would actually be incorrect.e.

We have standard times at my hospital, but that TID is wild, why so close together? What drug would that ever be appropriate for? We do 0730-1400-2000.

 

[bacillus1]

Yeah, if it's not going to harm the patient, then verify it, even if it seems silly. Remember the placebo effect is strong, and if someone feels better taking their QD medicine as 1/2 dose BID, then good for them.



We have standard times at my hospital, but that TID is wild, why so close together? What drug would that ever be appropriate for? We do 0730-1400-2200.

My thought is isosorbide IR as well as diuretics...can't think of anything else. I think the reason that it is the way it is is that 1000 is also DAILY and the morning dose of Q12H, 1400 is the afternoon dose of Q8H and 1800 is QPM...so that was the only way to do it without waking up the patients (elderly veterans) at 0600 or 2200 and keeping nursing admin times to a minimum.

 

[BidingMyTime]

My thought is isosorbide IR as well as diuretics...can't think of anything else. I think the reason that it is the way it is is that 1000 is also DAILY and the morning dose of Q12H, 1400 is the afternoon dose of Q8H and 1800 is QPM...so that was the only way to do it without waking up the patients (elderly veterans) at 0600 or 2200 and keeping nursing admin times to a minimum.

I meant 2000 for the last dose, not 2200, I edited my post to reflect that. What you said makes sense. What it boils down to is, nursing gets the times that nursing wants.

 

[Niosh]

meaning that they might pass meds every hour if all their patients have different admin times?

Technically possible, but in reality that never happens. Either I fix it at verification, or the nurse complains and I fix it later. Typically it's only stuff like antibiotics that get the q12 or q8 scheduling, regular chronic meds get their home dosing of BID, TID. We also have a 1 hour dosing window for most drugs, so if two meds are scheduled close enough together the nurse could just give one "early" and the other "late".

 

[ldiot]

Hi, hospital staff pharmacist here and I want to ask you guys few questions!
I am seeing many curve balls as I am verifying the orders.

If the frequency is different that what it says on Micromedex, but still under max dose would you guys verify? I got a clonidine order that is 0.1mg tid for blood pressure. I checked Micromedex and it says it's usually given BID (but max is 2.4mg/day)
I have numerous order sets like these. clonidine tid(?) lopressor 12.5 bid, lasix 80mg bid IV ?!

What the heck? You're a pharmacist? Anyone can look something up in micromedex, so why did you go to pharmacy school? Use your brain. By the way who uses micromedex as their reference to begin with?

 

[wsbkp08]

Yeah, if it's not going to harm the patient, then verify it, even if it seems silly. Remember the placebo effect is strong, and if someone feels better taking their QD medicine as 1/2 dose BID, then good for them.

Thanks this is what I need. Not BS like are you a pharmacist kind of questions.
My main question was what to do when drs keep entering orders that are NOT specifically listed in MicroMedex

What the heck? You're a pharmacist? Anyone can look something up in micromedex, so why did you go to pharmacy school? Use your brain. By the way who uses micromedex as their reference to begin with?

our hospital uses Micromedex. I hope we use lexicomp but we only have micromedex.
I look it up on Micromedex and things are different sometimes
I'm just being extra cautious

 

[sakigt]

1. You need a mentor at the hospital. Ask them questions. Feel comfortable doing this. Usually it starts with "Ive looked up this and this and this and I just wanted it to run it by someone more experienced."
2. Have other Pharmacists show you errors you made and appreciate their feedback.
3. The above advice about not looking everything up. Uh....yeah I looked up everything for the 1st year. Quickly. Id reject weird looking meds and do the "simple" ones so the screen didn't get out of hand