What is the best intervention you ever made?

[rxlea]

I'm tired of all this self-denigration in this forum.

Tell us what you've done for a patient that shows how badass pharmacists can really be 🙂

---

Members don't see this ad.

 

[joetrisman]

I'm tired of all this self-denigration in this forum.

Tell us what you've done for a patient that shows how badass pharmacists can really be 🙂

I've made two interventions while that were significant to me (as opposed to playing IV to PO, CrCl adj, and DVT/PUD police). One had a culture report that was sensitive to an abx we were treating with and then later came back with the final report as changed to intermediate. No one on the team caught it so I finally brought it to attention before moving on to the next patient.

The other was a septic patient not being treated appropriate according to the guidelines in abx choice and had an APACHE II score of 35. I brought this to the attention of my preceptor and subsequently the attending and made the correct recommendation. Lady ended up pulling through. I'd be more specific, but I told this story a lot recently 😎

 

[Sparda29]

I remember one time when I was an intern at CVS, some medical resident wrote for Lisinopril for a pregnant lady. Called up the hospital, asked for the attending physician, informed about the pregnancy category. I could hear the attending physician yelling like a maniac at the resident. Almost felt bad for the resident.

 

[bacillus1]

A few weeks ago the physician wrote for lisinopril for a patient who had an ACE allergy (angioedema). The patient received it for a day or 2 as an inpatient, but I noticed the allergy upon processing his discharge prescriptions, and immediately walked as fast as I could to the patient to tell him not to leave the hospital until we change his BP meds.

Another one a few months ago was that a physician started a pt. on warfarin as an inpatient, but forgot to continue his warfarin therapy as an outpatient. It would probably be caught at his first anticoag clinic appt, but he could clot by then.

 

[Pharmacy Kid]

A bunch of people with PMH of gastric bleeding being prescribed NSAIDS.

A person on methotrexate who's WBC's were trending down for the past 3 months.

A person with UDS +cocaine being prescribed Percocet.

 

[Recycled]

I'm tired of all this self-denigration in this forum.

Tell us what you've done for a patient that shows how badass pharmacists can really be 🙂

Patient presented to pharmacy for "best anti-itch cream out there." No patient profile since we weren't the pt's typical pharmacy. After discussion about rash location/onset and recently started Bactrim therapy, referred to ER for possible and later confirmed SJS.

How about you?

 

[WVUPharm2007]

Probably this.

I can't believe I missed the necrobump last year by the dude from Yale wanting more info. I missed my chance to be published. Oh well. Its not like I give a flying **** about that sort of thing. If anyone sees that dude, tell him my source was Remingtons.

 

[rph3664]

This wasn't me, but I had a colleague who noticed that a woman had refilled her husband's Nitrostat several times in the past few weeks. He asked her about it, and she said, "I have a hiatal hernia, and I found out that this works for me." 😱 He told her that this was probably not a hiatal hernia and to see a doctor that day, and about a week later, she came in with a pile of RXs from a cardiologist in the nearest big city.

I had a faxed prescription from a pediatrician who ordered something (I don't remember what) for a small child, and it seemed like a really big dose. The mom wasn't happy that she had to come back later, but it turned out he'd entered "teaspoons" instead of "milliliters" into the computer, and told her that if we had not intervened, it could have killed the child.

 

[GreyFox2002]

This wasn't me, but I had a colleague who noticed that a woman had refilled her husband's Nitrostat several times in the past few weeks. He asked her about it, and she said, "I have a hiatal hernia, and I found out that this works for me." 😱 He told her that this was probably not a hiatal hernia and to see a doctor that day, and about a week later, she came in with a pile of RXs from a cardiologist in the nearest big city.

I had a faxed prescription from a pediatrician who ordered something (I don't remember what) for a small child, and it seemed like a really big dose. The mom wasn't happy that she had to come back later, but it turned out he'd entered "teaspoons" instead of "milliliters" into the computer, and told her that if we had not intervened, it could have killed the child.

Was it a triple A?

 

[GreyFox2002]

One day at work my technician was complaining of nausea and generalized malaise. Generally she works very quickly but seemed so sluggish so I asked her what else was going. Upon questioning I found that she had a headache and a very stiff neck, but no rash or photophobia. Luckily the local ER was less then a half-mile away so I had her boyfriend take her up there. Expecting her to be out for a couple weeks, I started calling around for tech coverage. I didn't give her what I thought she had so I wouldn't alarm her.

The following night I get a phone call from her (from home!) telling me that she now is having a rash on her lower back and it hurts to look at lights. I was stunned she was at home and found out that the local ER diagnosed her with muscle spasms and gave her Flexeril and Motrin. I told her to go right to the university hospital near where she lived and tell them that your boss says you have meningitis and to get a spinal tap.

Thankfully it turned out to be aseptic, but my god. The local ER never even took cultures!!! Who could ignore those signs?

 

[rph3664]

More than once, when I was in both hospital and retail, I would get phone calls from someone who said a person they lived with was having this or that problem, and I would reply, "Get off the phone with me and call 911."

We're talking about things like crushing chest pain, "hallucinations", etc.

 

[tungsten87]

on my first day of hospital IPPE we were being shown all of the meds on the crash cart that was used for codes. i noticed that the chewable aspirin dose was 162 mg instead of the 325 mg dose we were taught a months prior in our ACS lecture in therapeutics. I notified the technician and found out from the students who were scheduled the next day that the protocol had been changed and it was now dosed at 325 mg. not sure if the prior dose was subtherapeutic or not but still pretty cool for a P2.

 

[xiphoid2010]

Intubated pt in MICU on fentanyl and ativan, s/p respiratory failure and brain anoxia, minimally responsive to stimuli. 2 weeks of vent wean failed due to agitation during all attempts. Medical team had family ready to go hospice.

I recommended considering dc ativan, switch to the non-formulary and very expensive precedex as a last attemp. I was basing it on internship in major medical centers and clinical trials data. None of the MDs and nurses were even familiar with the medication, but accepted it and ask pharmacy to dose and teach nursing how to manage it.

Pt made near miraculous progress, mental status came back in 3 days, vent wean successfully and pt extubated 1 week from the start date.

There are interventions that you make all day long, but most are really not likely to make a huge difference. But the one time that you clearly saved a life right before your eyes, it has a big effect on how you view what your job and duty means.

 

[VCU07]

Here are a couple of mine over the past few months:
1. Pt. transferred to unit s/p rapid response for bradycardia. After reviewing the pts. meds, I noticed the pt. has been started on a dig load....this load went on for days until I caught it in the unit. Asked the attending to order a stat dig level. Digibind started.
2. Yet another dig story. Pt. s/p cabg, coded in unit. I noticed pts. renal fx has crapped out and pt. went into a symptomatic bradycardia. Asked attending for a stat dig level...he refused, but later ordered one for the next am. Came back at 7....I wonder what it was during the code?

 

[Praziquantel86]

Recommending chloramphenicol for a dapto-resistant VRE meningitis in a patient two weeks post allo-SCT. His CSF cleared in two days, made it out of the hospital alive.

 

[xiphoid2010]

Recommending chloramphenicol for a dapto-resistant VRE meningitis in a patient two weeks post allo-SCT. His CSF cleared in two days, made it out of the hospital alive.

While there is no guidelines on VRE meningitis that I'm aware of, I'm not a fan of daptomycin for meningitis due to its poor penetration (< 1/20th of plasma concentration even in inflamed meninges) and enterococcus is considered to be susceptible if MIC is 4 or less (higher than MRSA). So even if you do 8-10 mg/kg, the time above MIC in CSF will be short. I would have preferred Zyvox as the main, and adding either rifampin, synercid (if faecium), even tygacil on top of it as adjunct, and gent synergy depending on the case.

Chloramphicol is one of those drugs you don't know if you saved or killed someone. The agranulocytosis is not dose dependent and has erratic onset from days to years after the drug. Truly is the drug of last resort.

 

[MackandBlues]

Dont remember my best but made a good one yesterday - stroke alert patient came in still within the time frame. Neurology and EC docs were getting ready to give TPA but patient had an ischemic stroke 2 months ago so I prevented them from giving the drug.

 

[Praziquantel86]

While there is no guidelines on VRE meningitis that I'm aware of, I'm not a fan of daptomycin for meningitis due to its poor penetration (< 1/20th of plasma concentration even in inflamed meninges) and enterococcus is considered to be susceptible if MIC is 4 or less (higher than MRSA). So even if you do 8-10 mg/kg, the time above MIC in CSF will be short. I would have preferred Zyvox as the main, and adding either rifampin, synercid (if faecium), even tygacil on top of it as adjunct, and gent synergy depending on the case.

Chloramphicol is one of those drugs you don't know if you saved or killed someone. The agranulocytosis is not dose dependent and has erratic onset from days to years after the drug. Truly is the drug of last resort.

I wouldn't have used dapto for meningitis either, but just thought it would describe the bug more accurately. We went with chloramphenicol strictly because it was meningitis, with a large amount of clinical experience (overall, not me specifically) using it for meningitis before there were other good options. We did switch to linezolid once the CSF cleared.

 

[BidingMyTime]

Very interesting to read these stories.

well, I have made some life-saving ones....one that comes to my mind is a doctor who ordered Duragesic 250mcg for a patient who had never been on Duragesic before. It was not a typo on his part, and it took quite a bit of explanation on my part to convince him this was deadly dosage, I have no idea what kind of conversion he was using-probably a math error, but he was quite convinced that his conversion of the patient's narcotic usage justified that high of a dosage.

 

[npage148]

Well, duragesic doesn't come in 250mcg/hr so...

 

[Carboxide]

Well, duragesic doesn't come in 250mcg/hr so...

Right but it's common to order it that way and to dispense in 2 100 mcg/hr patches + 1 50 mcg/hr patch. Happens all the time.

 

[rph3664]

Right but it's common to order it that way and to dispense in 2 100 mcg/hr patches + 1 50 mcg/hr patch. Happens all the time.

True, for a terminal patient in hospice, but not for an opiate-naive patient.

 

[Carboxide]

True, for a terminal patient in hospice, but not for an opiate-naive patient.

Oh, definitely. Seriously, 250 mcg/hr fentanyl is about 800 mg oycodone QD....NOT appropriate EVER in that situation. Simply addressing the dose form there.

 

[Sparda29]

There was a resident who absolutely insisted on ordering Vancomycin 1 mg (milligram) q12h. I kept asking him if he meant 1 gm q12h but he kept insisting on mg. E-mailed him a screenshot of Lexicomp's Vanco page and then an hour later, I see the order change on the EMR.

 

[WVUPharm2007]

There was a resident who absolutely insisted on ordering Vancomycin 1 mg (milligram) q12h. I kept asking him if he meant 1 gm q12h but he kept insisting on mg. E-mailed him a screenshot of Lexicomp's Vanco page and then an hour later, I see the order change on the EMR.

That's when you call the actual hospitalist (or any physician, really) that's there and tell them to tell the newb he's an idiot. Happened to me once when an "enalapril 25mg IV" came floating across my desk. If you have a good repertoire with them you can call them up and be like, "Hey, Blake, it's Mike. Go tell this Resident by the name of....Uh...Patel, that he's stupid and trying to kill his patient with this enalaprilat dose. He won't listen to me. K, Thx, Bye."

Then they usually make them call you to apologize and its hilarious.

 

[Sparda29]

That's when you call the actual hospitalist (or any physician, really) that's there and tell them to tell the newb he's an idiot. Happened to me once when an "enalapril 25mg IV" came floating across my desk. If you have a good repertoire with them you can call them up and be like, "Hey, Blake, it's Mike. Go tell this Resident by the name of....Uh...Patel, that he's stupid and trying to kill his patient with this enalaprilat dose. He won't listen to me. K, Thx, Bye."

Then they usually make them call you to apologize and its hilarious.

I wanted to, but I kinda felt bad for the guy since it was like the first week the for the new residents (1st years)

 

[awval999]

Every PGY-1 resident I've ever had to speak to has been over the top nice and apologetic when I call them about their errors.

Then again I'm super over the top nice and professional when I speak to them. I always call them Dr. so and so, sorry for the interruption, I see this order on the eMAR, but I think you meant to order.......