Item

Notes

Policy/
Reference

1

Clinical Interventions

Enters CI into Theradoc

2

Kronos

3

LEARN

4

Schedule & Assignments

12 week Schedule, Swapping Policy, WhenToWork, Time Off Requests

5

Anticoagulation Management Policy

Premixed heparin, INR rules, warfarin tablet splitting, etc.

MM-05401

6

Calcium Intravenous Infusion Policy

Calcium chloride vs calcium gluconate

MM-05417

7

Cardiac IV, Continuous Infusion Drips & Patient Placement Policy

Identify unit specific drips, protocols, restrictions

MM-05416

8

Central Line Flushes

Saline flushes for most uses; heparin only for Port-a-cath

PC-07124

9

Clinical Pharmacology

Pediatric Dosing, Drug Identifier, IV compatibility, drug interactions, printing patient education

See Clinical Pharmacology

10

Electrolyte Protocol

New electrolyte orders, Magnesium PO replacement orders per protocol

11

eMAR Competency

Understand how orders appear on the eMAR

12

Epidural Analgesia Policy

CNS depressants cannot be given without anesthesia approval

MM-05408

13

Formulary Designations

Understand Formulary Non-stock, NF Specialty, NF designations & utilize flowcharts for handling orders

See FormWeb

14

Formulary Interchange document

Includes all formulary interchanges, restrictions, & usage criteria

See FormWeb

15

Heparin wt. based protocol

16

Home Medication Dispensing workflow

Receive and dispense patient home medications per policy

17

Hypertonic Saline Policy

Understand guidelines for appropriate use of hypertonic saline (max rates, specified volumes, etc.)

MM-05465

18

Intensivists / Hospitalists / CVTS / Infectious Disease specialists

Be able to identify these specialists and which meds are restricted to service lines

19

IV fluids from CSR

Recognize which IV fluids are supplied by CSR vs pharmacy admixture

See FormWeb

20

IV Label Printers

PHA6 (main IV), PHAS (STAT IV), PHA5 (duplicate labels)

21

Missing Med Processing

Research missing med requests prior to debiting

22

New Consult Protocols

Documentation via Meditech clinical interventions

23

Non-formulary Pricing

NF entry, referral to management for pricing

24

Potassium Chloride Infusions Policy

Max rates, central vs peripheral lines

MM-05430

25

PRN Orders Policy

PRN indication required; see policy for default options

MM-05422

26

Processing the status board

27

Procrit HD doses

28

Pyxis

MedStation, Console & CII Safe

29

Pyxis Connect Competency

30

Sedative/Hypnotic Policy

Max dose Ambien; Benadryl restrictions; substitutions

MM-05410

31

SSU & Home Medication Orders

If patient being discharged, evaluate need for entering

32

Standard Concentrations for IV Drips

Follows Memorial IV Stability Guidelines/Max Concentrations (FormWeb document)

See FormWeb

33

Therapeutic Duplication of PRN Medication Orders Policy

All PRN orders must have clear instructions for use (must be distinguishable from other PRN orders)

MM-05475

34

Time Change Requests 

Maintain standard dosing times when feasible

35

“Do Not Load” list

Most DNL items suppressed from load list; see FW for list

See FormWeb

36

“Do Not Tube” list

Posted at tube station

37

After-hours Outpatient Pharmacy Access

2 pharmacy employees (1 pharmacist) + security

38

Alcohol Withdrawal Protocol

39

Antibiotic Stewardship Protocols

Restricted abx, dosing protocols (Zosyn, Cefepime, Meropenem), dose adjustments, etc.)

40

Antidote Document

Utilize FormWeb referecne for antidotes and their use

41

Antithrombin III replacement protocol - ECMO

42

Antithrombotic Reversal/Surgical Management Recommendations

Utilize FormWeb referecne for questions / recommendations regarding antithrombotic reversal

See FormWeb

43

Aseptic IV Technique/ Sign OFF (in file)      

44

Auto-stop protocols (Tamiflu, Zmax, Entereg)

45

Basic RXM competency

46

Blood Factor Products for Inherited Bleeding Disorders

Understand appropriate use of blood factor products based on indication

See FormWeb

47

Borrow/Loan Procedure

Utilize forms under window in main pharmacy

48

Central Venous Access Device: Thrombolytic Declotting for Occlusion

Orders for tPA for catheter thrombolysis will not be dispensed until evaluated by IV team; await phone call from IV team

PC-07138

49

Charity Medication Policy

Follow policy for after-hours dispensing of charity meds

PHRM-POL-654

50

ChartMaxx

Uses ChartMaxx to obtain info from closed charts (ADR’s, Vanco reviews, etc)

51

Chemo

Understands chemo preparation guidelines, safety form, dosing, dispensing; NP chemo

MM-05426

52

Chemotherapy & Biologic Dose Rounding Policy

Remicade, Rituxan, IVIG (appropriate weight based dosing)

See Policy

53

Code Response

Assigned pharmacists respond to every code with code box

54

Compounding Log Documentation

Location of compounding log, purpose and use

55

Courier

Contacts and utilizes courier service appropriately

56

CRRT/Citrate Report & protocol

Communicate with SPS regarding citrate rates/quantities

57

Daptomycin standard dosing times process

Given at 2100; follow Meditech prompt for determining need for "now" dose on order entry

58

Department medication orders

Wound Center, Respiratory, EMS

59

Erthyromycin IV to Azithromycin IV Conversion

60

Extravasation Document

Utilize FormWeb reference for questions regarding treatment of extravasations

See FormWeb

61

G-drive

Understand how to access, enter, and save data via G-drive

62

High Alert Medications Policy

Know high alert medications and special handling procedures

MM-05402

63

HIT – Argatroban / Angiomax / Arixtra

Understands appropriate medication / protocol for HIT or suspected HIT

64

HIV Post-exposure Prophylaxis

Understands proper procedure/meds to dispense for blood/body fluid exposure; utilize PEP notebook

IC-06032

65

Hixson Patient Transfers

Manually re-enter all continued medications for receiving facility

66

Insulin Pump Policy

Patient assumes primary responsbility under physician supervision, vials sent from pharmacy when needed to refill pump

PC-07236

67

Insulin U-500 Administration Policy

Dose ordered in both units & volume, pharmacist to verify dose, dispensed in TB syringe

MM-05439

68

Intubation Kits/transport kits/ Emergency Boxes

Familiar with kits for ED, ICU’s

69

Investigational Drug Protocols

Identifies, documents, and dispenses per Memorial policy

MM-05451

70

IRIS Reporting, ADE reporting

Familiar with system reporting both ADRs and Med Occurences

71

Isuprel drips – SSU/EP Lab 50ml drips for test

Understands use of Isuprel as test indicator (non-cardiac drips), preferred use of dopamine for therapeutic dosing

72

IV Iron Replacement Protocol

Iron dextran/sod. Ferric gluconate; calculator on FormWeb

73

IV Levothyroxine Dose Conversion

IV doses given Q 48 hrs to avoid waste

74

IV to PO Conversion Policy

Understand criteria for inclusion/exclusion

PHRM-0535

75

Lactated Ringers Compatibility

Utilize reference on FormWeb

See FormWeb

76

Load List Review

Utilize load list guidelines in main pharmacy

77

Medication Reconciliation Service Protocols

Admission med history techs; discharge process

78

Miacalcin IV

See FormWeb reference for appropriate use

See FormWeb

79

Outlook & Lync Communication

80

Post-splenectomy vaccine protocol

See FormWeb for references

See FormWeb

81

Reclast for Breast Center & Ooltewah

Sent from outpatient pharmacy to main pharmacy, kept in refrigerator #17, picked up in AM in main pharmacy

82

Refrigerator Checks

Checked 3x/day, documented on G drive spreadsheet

83

Responder 5 & ASCOM Procedures

Look up RN assignments & contact via ASCOM phone

84

S-A-L-A-D

Know look-alike sound-alike drug list for MHS

See List

85

Shortage List

Posted in main pharmacy, on G drive weekly

86

TheraDoc

Clinical alerts, pharmacy assistant, intervention review, etc.

87

Thyrogen

Utilize set. Dispense 1 kit (containing 2 vials).

88

Tikosyn

Understands dispensing restrictions, protocol

89

TPA Stroke Protocols

Follows tPA stroke protocol; location of kit in ED pyxis; formweb references for dosing; pharmacist stroke response, including kit location and handling phone calls

90

TPE Protocol

TPE orders for next day; LE when needed

91

Unapproved abbreviations

Know unapproved abbreviations specific to MHS

IM-02037

92

Vaccines

Utilize sets; flu & pneumonia vaccines have admin fees

93

Zosyn Extended Infusion Compatibility

Compatibility studies done, reference on FormWeb

See FormWeb