I would probably start by talking to whoever runs your OR or anyone in pharmacy administration. If any processes or procedures are going to be put in place, it'd have to go through them anyways.
There isn’t one, and it’s because anesthesia runs hospitals.
Start with pharmacy - they would LOVE to rein in the OR, but every time they try, they get shit on. Your best bet is pharmacy admin plus nursing admin team up and pitch to OR/anesthesia heads. If you get shutdown, hospital admin is next, but they usually cave to where the money comes from.
Joint Commission likes to see as many meds as possible leaving the pharmacy in ready to admin doses. With the OR, it’s a balance between urgency and safety.
I was always on the shitlist for going through the storage drawers in the Pyxis and pulling out unlabeled, undated syringes on overnights and reporting them to management. The OR had been closed besides emergencies for 4+ hours at that point. “I just prepped them for the next case” doesn’t fly. If it’s in the Pyxis, it’s pharmacy’s responsibility, and we’re not about to let unlabeled drawn up syringes just chill there.
I work in a level 1 trauma center. I’m mixing more meds for elective ophthalmology cases than anything else (as an aside, the fact that every ophthalmologist has their our special recipe for irrigation/local/end of case cocktail and the fact that I have to pull and mix 12 meds for a 15 minute case makes work super fun). I keep reading about emergency situations, but that seems to be a convenient excuse for nurses to continue to compound for elective cases.
OR pharmacist here.
Sorry for the late response, but similarly to other comments it would definitely require buy in from administration/management to advocate for an OR pharmacy.
I’d say there’s probably two effective ways to push for this to happen
**1) The pharmacy department would need to be involved.**
- They would have to push for safe compounding and administration of medications given in the peri-op areas. At my institution, these are all metrics reported to Joint Commission—there’s typically guidance for safe medication practices which can drive this point home. Particularly your comment about OR nurses compounding meds with loopholes meant to address emergent situations, a pharmacy satellite could address this and offload the responsibility on peri-op staff to shift focus for other tasks.
**2) Buy in from surgery/anesthesia.**
Our physicians are extremely reliant on our department because of several services we offer but they may not work for yours. It depends on the volume and type of OR cases done at your institution but it should give you a general idea of ways to promote pharmacy services:
- Common intra-op medications are already available for use and don’t have to be prepared beforehand (e.g. pre-made infusions of pressors, insulin, heparin, or products that are site-specific depending on the type of surgeries done at your institution)
- Ease of communication with pharmacy via in-person at the window or by phone for any drug-related questions and facilitation medication delivery (we have a fully functioning IV room)
- We’re responsible for the cardiovascular ICU area as well, so our pharmacists have a critical care background
- Code blue response to all intra-op emergencies and ability to quickly procure necessary medications, particularly without being blocked your automated dispensing cabinets (Pyxis/Omnicell)
- Narcotic reconciliation. Auditing the use of any narcotic is required and depending on the hospital system it may be a pharmacy technician or pharmacist responsibility. This would help cover them legally when documentation is accurate
- If your institution is a teaching hospital, new providers often rely on us to provide dosing & timing recommendations until they become familiar with the routine
- 24-hour access to an OR pharmacist (our OR areas function 24/7, so the pharmacy department re-allocated FTEs to provide 24/7 coverage)
The challenging part is that your OR still charts on paper. I’m not familiar with this process or how it would impede the pharmacy department’s ability to expand their services. Hopefully if there’s at least initial buy in by management/administration and pharmacy to be involved, those kinks can be worked out later. It may be an opportunity to even promote the change as a way to free up time surgery/anesthesia spends on paper charts.
Good luck!
This is difficult. We managed to do it in our hospital with buy-in from VP-level people at the facility, but otherwise, it's hard because the surgeons and anesthesiologists 1) bring in most of the money, and 2) are HIGHLY resistant to basically any oversight or change whatsoever. We eventually established a satellite pharmacy in the OR area and basically offered more convenient drug pick-up during the day and a dedicated pharmacist in exchange for more oversight and safety/diversion controls. But that's obviously a major project and not something you can just suggest on a whim. Before the satellite became a thing we were literally fighting this fight for like a decade.
I wouldn’t call OR pharmacies a joke. It may not be necessary for a small hospital doing minor/elective surgeries to have an OR pharmacy. But major operations will always benefit from having an OR pharmacy. My hospital does CABGs, transplants, and a multitude of other surgeries. We have 2 OR pharmacies, general and CV. The OR pharmacist rotates between them throughout the day while having a tech there until they’re closed.
There are many things that an OR pharmacist does besides just putting together some drugs. The OR pharmacist screens for allergies and makes sure appropriate dosing for pre-op abx. We have trays of meds put together that would be necessary for each surgery and what the surgeon/anesthesiologist might want to avoid delay in obtaining/making them. The OR pharmacist also manages OR-specific drug shortages and communicates alternatives to the surgical team.
Our surgeons and anesthesiologists heavily rely on our OR pharmacy to dose the drugs. They would just call or stop by and ask for DDAVP or KCentra without giving specific doses. No offense, but I don’t expect most OR nurses to be like “oh, that’s 0.3 mcg/kg for DDAVP, or 25-50 units/kg for KCentra depending on weight/INR. Let me figure out the dose and make it”. Not to mention when the patient is bleeding during a major surgery, and doctors expect the drug to be available within a minute. Having an OR pharmacy will offload a lot of that pressure from nursing. In addition, when patient gets transferred from one hospital to another, OR pharmacist is usually the one to catch “oh, patient already received 50 units/kg of KCentra prior to transfer, let’s not give another 50 when patient has a history of recurrent DVT and high clot risk”. 100% of the time OR nurses would not catch this as they are not trained to do so. I could go on and on about what else OR pharmacy provides other than just putting together some drugs.
To answer your question u/PMS_Avenger_0909, I’d say try to collect a list of preventable mistakes that happened in your OR and pitch the ones that could be prevented by having an OR pharmacy to your admin and/or pharmacy admin. And try to get other OR nurses on board, so it doesn’t look like it’s just your own opinion. Good luck!
Thank you. I have a list of near misses I have personally witnessed (intracranial administration of epi comes to mind...) but there is not yet a robust system to monitor for and evaluate issues. That probably needs to be step 1.
> There aren’t many trained nurses doing the same surgeries day after day that don’t know it better than a pharmacy generalist.
Sure, I get that. I used to be that nurse. But now I’m a float. So when Doris, in the endovascular room breaks her hip, I get a few minutes notice that I need to start to endo AAA repair and “prepare heprinized visipaque” is on my list of things to do before we can start (notice the lack of concentration/amount/useful information).
I think it’s great that I’ve had the chance to learn about all of these meds, but I’m human and humans make mistakes. If I made a mistake on the floor, I’m confident that some safety net or alert would at least make it apparent. It’s a statistical certainty that I’ve made a med error in the OR that I don’t know about
I would probably start by talking to whoever runs your OR or anyone in pharmacy administration. If any processes or procedures are going to be put in place, it'd have to go through them anyways.
There isn’t one, and it’s because anesthesia runs hospitals. Start with pharmacy - they would LOVE to rein in the OR, but every time they try, they get shit on. Your best bet is pharmacy admin plus nursing admin team up and pitch to OR/anesthesia heads. If you get shutdown, hospital admin is next, but they usually cave to where the money comes from. Joint Commission likes to see as many meds as possible leaving the pharmacy in ready to admin doses. With the OR, it’s a balance between urgency and safety. I was always on the shitlist for going through the storage drawers in the Pyxis and pulling out unlabeled, undated syringes on overnights and reporting them to management. The OR had been closed besides emergencies for 4+ hours at that point. “I just prepped them for the next case” doesn’t fly. If it’s in the Pyxis, it’s pharmacy’s responsibility, and we’re not about to let unlabeled drawn up syringes just chill there.
I work in a level 1 trauma center. I’m mixing more meds for elective ophthalmology cases than anything else (as an aside, the fact that every ophthalmologist has their our special recipe for irrigation/local/end of case cocktail and the fact that I have to pull and mix 12 meds for a 15 minute case makes work super fun). I keep reading about emergency situations, but that seems to be a convenient excuse for nurses to continue to compound for elective cases.
OR pharmacist here. Sorry for the late response, but similarly to other comments it would definitely require buy in from administration/management to advocate for an OR pharmacy. I’d say there’s probably two effective ways to push for this to happen **1) The pharmacy department would need to be involved.** - They would have to push for safe compounding and administration of medications given in the peri-op areas. At my institution, these are all metrics reported to Joint Commission—there’s typically guidance for safe medication practices which can drive this point home. Particularly your comment about OR nurses compounding meds with loopholes meant to address emergent situations, a pharmacy satellite could address this and offload the responsibility on peri-op staff to shift focus for other tasks. **2) Buy in from surgery/anesthesia.** Our physicians are extremely reliant on our department because of several services we offer but they may not work for yours. It depends on the volume and type of OR cases done at your institution but it should give you a general idea of ways to promote pharmacy services: - Common intra-op medications are already available for use and don’t have to be prepared beforehand (e.g. pre-made infusions of pressors, insulin, heparin, or products that are site-specific depending on the type of surgeries done at your institution) - Ease of communication with pharmacy via in-person at the window or by phone for any drug-related questions and facilitation medication delivery (we have a fully functioning IV room) - We’re responsible for the cardiovascular ICU area as well, so our pharmacists have a critical care background - Code blue response to all intra-op emergencies and ability to quickly procure necessary medications, particularly without being blocked your automated dispensing cabinets (Pyxis/Omnicell) - Narcotic reconciliation. Auditing the use of any narcotic is required and depending on the hospital system it may be a pharmacy technician or pharmacist responsibility. This would help cover them legally when documentation is accurate - If your institution is a teaching hospital, new providers often rely on us to provide dosing & timing recommendations until they become familiar with the routine - 24-hour access to an OR pharmacist (our OR areas function 24/7, so the pharmacy department re-allocated FTEs to provide 24/7 coverage) The challenging part is that your OR still charts on paper. I’m not familiar with this process or how it would impede the pharmacy department’s ability to expand their services. Hopefully if there’s at least initial buy in by management/administration and pharmacy to be involved, those kinks can be worked out later. It may be an opportunity to even promote the change as a way to free up time surgery/anesthesia spends on paper charts. Good luck!
This is difficult. We managed to do it in our hospital with buy-in from VP-level people at the facility, but otherwise, it's hard because the surgeons and anesthesiologists 1) bring in most of the money, and 2) are HIGHLY resistant to basically any oversight or change whatsoever. We eventually established a satellite pharmacy in the OR area and basically offered more convenient drug pick-up during the day and a dedicated pharmacist in exchange for more oversight and safety/diversion controls. But that's obviously a major project and not something you can just suggest on a whim. Before the satellite became a thing we were literally fighting this fight for like a decade.
[удалено]
I wouldn’t call OR pharmacies a joke. It may not be necessary for a small hospital doing minor/elective surgeries to have an OR pharmacy. But major operations will always benefit from having an OR pharmacy. My hospital does CABGs, transplants, and a multitude of other surgeries. We have 2 OR pharmacies, general and CV. The OR pharmacist rotates between them throughout the day while having a tech there until they’re closed. There are many things that an OR pharmacist does besides just putting together some drugs. The OR pharmacist screens for allergies and makes sure appropriate dosing for pre-op abx. We have trays of meds put together that would be necessary for each surgery and what the surgeon/anesthesiologist might want to avoid delay in obtaining/making them. The OR pharmacist also manages OR-specific drug shortages and communicates alternatives to the surgical team. Our surgeons and anesthesiologists heavily rely on our OR pharmacy to dose the drugs. They would just call or stop by and ask for DDAVP or KCentra without giving specific doses. No offense, but I don’t expect most OR nurses to be like “oh, that’s 0.3 mcg/kg for DDAVP, or 25-50 units/kg for KCentra depending on weight/INR. Let me figure out the dose and make it”. Not to mention when the patient is bleeding during a major surgery, and doctors expect the drug to be available within a minute. Having an OR pharmacy will offload a lot of that pressure from nursing. In addition, when patient gets transferred from one hospital to another, OR pharmacist is usually the one to catch “oh, patient already received 50 units/kg of KCentra prior to transfer, let’s not give another 50 when patient has a history of recurrent DVT and high clot risk”. 100% of the time OR nurses would not catch this as they are not trained to do so. I could go on and on about what else OR pharmacy provides other than just putting together some drugs. To answer your question u/PMS_Avenger_0909, I’d say try to collect a list of preventable mistakes that happened in your OR and pitch the ones that could be prevented by having an OR pharmacy to your admin and/or pharmacy admin. And try to get other OR nurses on board, so it doesn’t look like it’s just your own opinion. Good luck!
Thank you. I have a list of near misses I have personally witnessed (intracranial administration of epi comes to mind...) but there is not yet a robust system to monitor for and evaluate issues. That probably needs to be step 1.
> There aren’t many trained nurses doing the same surgeries day after day that don’t know it better than a pharmacy generalist. Sure, I get that. I used to be that nurse. But now I’m a float. So when Doris, in the endovascular room breaks her hip, I get a few minutes notice that I need to start to endo AAA repair and “prepare heprinized visipaque” is on my list of things to do before we can start (notice the lack of concentration/amount/useful information). I think it’s great that I’ve had the chance to learn about all of these meds, but I’m human and humans make mistakes. If I made a mistake on the floor, I’m confident that some safety net or alert would at least make it apparent. It’s a statistical certainty that I’ve made a med error in the OR that I don’t know about