Hospital Pharmacy Operations Flashcards

A hospital pharmacist is asked to review an order for intravenous acetylcysteine for paracetamol overdose. The standard adult regimen involves three bags. What is the sequence?

Answer: Bag 1: 150 mg/kg over 1 hour → Bag 2: 50 mg/kg over 4 hours → Bag 3: 100 mg/kg over 16 hours (in 5% dextrose)

The standard IV NAC (acetylcysteine) regimen for paracetamol overdose is three-bag: (1) 150 mg/kg in 200 mL D5W over 1 hour (loading), (2) 50 mg/kg in 500 mL D5W over 4 hours, (3) 100 mg/kg in 1,000 mL D5W over 16 hours = 300 mg/kg total over 21 hours. Concentration errors between bags are a known safety risk.

A clinical pharmacist identifies that a post-operative patient has not had their pre-operative diabetes medications reconciled. Which medication requires the most urgent attention?

Answer: Long-acting insulin and oral antidiabetics — uncontrolled perioperative hyperglycemia increases surgical site infection and mortality

Perioperative glycemic control (target 140–180 mg/dL in most patients) is critical as hyperglycemia impairs wound healing, increases infection risk, and worsens outcomes. Oral antidiabetics (especially metformin — hold 24–48h pre-op and until renal function confirmed post-op) and insulin regimens require careful perioperative adjustment.

The pharmacy department implements 'tall man lettering' and receives pushback from some staff who say the mixed-case names are harder to read. What is the pharmacist's response?

Answer: Evidence supports tall man lettering for LASA error prevention — the minor reading adjustment is justified by the significant reduction in medication errors

Tall man lettering is an evidence-based, internationally recommended (FDA, ISMP, WHO, CBAHI) patient safety measure for LASA medications. While it requires adjustment for staff accustomed to standard text, the reduction in medication errors from name confusion significantly outweighs the minor inconvenience. Staff education facilitates adoption.

A pharmacist is reviewing an aminoglycoside dose for a patient with a creatinine clearance (CrCl) of 30 mL/min. Standard dose is 5 mg/kg/day. How should this dose be modified?

Answer: Reduce the dose or extend the dosing interval based on CrCl — multiple dosing nomograms exist; typically extend interval to every 36–48 hours

Aminoglycosides are renally cleared, and reduced CrCl requires either dose reduction or interval extension to prevent accumulation and toxicity. Multiple nomograms (Hartford, Sanford) guide dosing in renal impairment. For CrCl 30 mL/min, extending the interval to every 36–48 hours (rather than every 24 hours) is a common approach.

A pharmacist is reviewing a prescription for methotrexate for a patient with psoriasis. The dose reads 'MTX 7.5 mg daily.' What is the concern?

Answer: Methotrexate for non-oncology indications is prescribed WEEKLY not daily — daily dosing causes fatal myelosuppression

Methotrexate for rheumatoid arthritis, psoriasis, and other inflammatory conditions is always prescribed ONCE WEEKLY. Daily MTX (as used in some oncology regimens) causes severe, potentially fatal cumulative toxicity — myelosuppression, hepatotoxicity, and mucositis. MTX daily-vs-weekly is a high-alert prescribing error that pharmacists must catch.

A hospital pharmacist is asked to prepare a morphine patient-controlled analgesia (PCA) infusion. The order reads: 'Morphine 50 mg in 50 mL normal saline, bolus 1 mg, lockout 6 minutes, no basal rate.' What concentration should be prepared?

Answer: 1 mg/mL (50 mg in 50 mL)

Morphine 50 mg in 50 mL normal saline = 50/50 = 1 mg/mL concentration. At 1 mg/mL, a 1 mg bolus dose = 1 mL per bolus. This is a standard PCA morphine concentration. The 6-minute lockout prevents too frequent dosing. Verification of the concentration calculation is a critical pharmacist safety check.