Manual Section Code No.

Page 1
POLICY
Of 13
Effective Date: April 2, 2007
Subject: Orientation of New Pharmacists
Date Reviewed:
Date Revised:
Cross Index: Issued by: Pharmacy Manager Approved by: Pharmacy Manager

POLICY STATEMENT:

It is the policy of the Pharmacy Department at Southlake Regional Health Centre that all new staff
members complete a departmental orientation program in addition to the general SRHC orientation for
new employees.

GENERAL INFORMATION:

Southlake Regional Health Centre Pharmacy operates a decentralized order entry, unit dose distribution
system with supplemental wardstock. Medication carts are filled daily. The emergency department has
wardstock in an automated dispensing cabinet (Acudose) and a night cart is available for after hour
medication procurement. There is no formalized unit dose IV admixture program, however there are many
sterile IV items prepared by the pharmacy including TPN (pediatric and adult), chemotherapy, immune
globulin, cardioplegia and large volume potassium infusions. The pharmacy is involved in dispensing
Special Access and Clinical Trial medications and provides medications to select outpatients (clozapine,
mental health day patients, dofetilide special access).

All clinical pharmacists enter their own orders and may also have an order entry shift. Some may also
have additional administrative duties (eg. Committees). Clinical pharmacists are involved in patient
discharge counseling, patient classes (hip/knee school, lung school, psychiatric outpatient class), cardiac
preop clinic, the Arthritis Program, and Chemotherapy teaching. In addition, pharmacists provides clinical
coverage to all inpatient nursing units with more coverage dedicated to high risk patients and higher
funded programs.

The following will make up the components of the training program. Training times are general guidelines
and may vary according to the previous experience of the new pharmacist and clinical assignment.

 SRHC general orientation for new employees 2 days

 Computer order entry 4-6 weeks
 Patient Care 2-3 weeks
 Drug Delivery System 3 days
 Narcotic and Controlled Drugs 0.5 day
 IV Room/Sterile Procedures/TPN 1 week
 DUE/Drug Information/Hospital Library 1 day
 Chemotherapy Satellite - general 1 day
 Chemotherapy for Oncology Pharmacists 4 weeks

All new pharmacists are required to complete the Orientation Checklist for Pharmacists.
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PROCEDURE:

Each item is to be checked off when completed. The last page will be signed and dated when completed
and given to the Pharmacy Manager.

1. Tour of Pharmacy Trainer______________

 Order Entry
 Coat Room/Lockers
 Tube System
 Picking Stations
 Fridges, temperature monitors, alarmed to switchboard
 IV Room/Anteroom
 Prepacking
 Rolling Shelves
 Locker assignment
 Location of Disaster Cart
 Garbages/recycling/classified (shredding) waste

2. Scheduling/Hours of Operation/Shifts Trainer______________

Weekdays: 0730 to 2030 hrs

Shifts 0730 – 1530hrs (techs and pharmacists)

0800 – 1600hrs (chemo clinic satellite)
1000 – 1800hrs (1 pharmacist)
1230 – 2030hrs (1 tech/2 pharmacists)
1130 – 1930hrs (1 tech)

Weekends: 0800 to 1600hr (3 pharmacists/ 4 techs)

Stats: 0800 to 1600hr (3 pharmacists/ 8 techs) – 2-3/year

 Pharmacist Schedule Binder – current schedule, week-end/vacation planner

 Pharmacist weekly schedule with daily assignements
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3. Communication Trainer______________

 Phones – transferring, call pick up, call forward, headset operation

 Pagers – how to page someone, how to view a page, how to clear pager
 Swiping in/out/call back
 Fax machines – how to send a fax
 Printers – location of, refilling paper, replacing cartridges
 Scanning to e-mail or to file
 Department Bulletins – magnetic posting area near order entry
 Mail boxes
 Hospital mail room
 Physician mail room
 Photocopying
 Long Distance Code
 Intercom system
 Button to open the door
 Security System – video cameras, alarm, swipe access
 Vacation Request forms
 Floor Stock Adjustment Request Forms (ensure name of person making request is included)
 Medication incident reporting
 Reporting Order entry errors
 Safepoint
 Investigating any risk issue – inform manager verbally in addition to e-mail

4. Continuing Education (CE) Trainer______________

All pharmacists are expected to maintain an education learning portfolio as required by the Ontario
College of Pharmacists and are encouraged to participate in continuing education.
During your training period there will likely be topics that you

 Multidisciplinary Rounds (weekly on Tuesdays)

 Cardiology Lecture Series (weekly on Wednesdays)
 Pharmacy education sessions
 Conferences/certification programs/workshops encouraged for area of practice
 Present highlights of educational programs to department
 Request for Education Funding Form
 Application for Educational Assistance/Reimbursement Form
 Expense Report Form
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5. DRUG DISTRIBUTION SYSTEM

a) Order Entry Trainer(s)______________

There is at least one pharmacy in computer order entry at all times. All pharmacists will be required to
complete the Pharmacy Order Entry Training Exercises. Training begins in the test system followed by
supervised order entry in the live system. All live orders will be checked by another pharmacist until such
a time that the training pharmacist is entering error free.

 Signing on computers
 Order Entry Area
 Phone lists
 Physician Pager list
 Schedule binder and weekly schedule
 Pharmacist floor slots (“problem boxes”)
 Week-end problems folder
 Microbiology Faxed Reports from Sunnybrook
 Therapeutic Interchange List
 Therapeutic Interchange Order Sheets
 Physician Order Progress Sheets
 Protocols and Guidelines binder
 Pharmaceutical Sales Representative badges – get keys, collect business card and put date on it
 Contents of filing cabinets
 Reference books/Pharmacist’s Quick Reference Binder/Policies/Formulary
 Closing time – locking front door and window
 Shredding Confidential materials
 Operating Room lists
 Clinical Trials
 Patient Transfers
 Acute to Chronic/Rehab or MHU and vice versa
 MSA to MSR
 Dofetilide
 Read Dofetilide Formulary Addition Request
 Clinical Responsibility of Cardiac Pharmacists for dofetilide
 Dofetilide Control Log
 Patient information binders
 Storage of new patient supplies
 Inpatient orders – use patient specific supplies only
 Outpatient dispensing
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b) Interim Dose Picking Station Trainer______________

The interim dose picking station or the “upfront” is staffed by one technician for all hours of operation.
The pharmacist will be oriented to the duties performed by the “upfront” technician.

 Fill interim doses

 Week-end pass medications – filling and checking procedures
 Check all passes on 2 consecutive Fridays
 Night cupboards fill daily
 Night cupboards checked weekly
 Investigational/Special Access Medications
 Risperdal Consta documentation of sample dispensing
 Missing Medications – replace dose and demand dose computer entries
 Problem Solving
 Patient Transfer and Discharge Labels
 Code Cart Checking
 Stores Ordering, Ricoh Ordering
 AM Fridge & Freezer Check
 Stock Requisitions and Charging
 Birthing unit trays
 HIV and TB medications
 Borrowing and lending medications
 Medication order pickup and delivery times
 “Berry Bins” on nursing units
 Service Assistant and Technician delivery and pick up schedules
 STAT medication delivery
 Double checking of all multi-dose items, multivitamins and iron products

c) Bin Filling Trainer______________

Each day, medication cassettes are filled to provide a 24-72 hour supply of medications to the nursing
units. Computerized fill list are used to record the number of doses sent for every patient. The pharmacist
will be oriented to the duties performed by the bin filling technicians with attention to the appearance of
the fill list and implications for order entry.

 Fill station layout

 Running fill lists/Update lists
 Certification process for technicians
 Computer generated patient labels
 Stock replenishment on carts including charging (Stock Transfers)
 Discharges and Transfers
 Filling refrigerated items
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 Check carts after delivery for inhalers, creams, etc. Send back to floors with patient(s) and room
number
 Cart Delivery time and schedule

d) Narcotics Trainer______________

There is one full time Narcotic Technician responsible for Narcotic and Controlled Drug Distribution. The
pharmacist will be oriented to the duties performed by the Narcotic technicians in order to be able to check
the work of the narcotic technician and dispense narcotics when required.

 Tour of narcotic room

 Distribution of narcotics and controlled drugs to nursing units
(shadow technician for several deliveries)
 Signing procedures for issuing and returning narcotics and controlled drugs
 Location of key to narcotic vault
 Checking Anesthetist boxes
 Returning incomplete sheets to nursing units
 Checking Anesthetist drug boxes
 Ambulatory day care box exchanges
 CT box exchange
 Narcotic room inventory
 Methadone for pain
 Methadone for narcotic dependency
 Computer charging for narcotics and controlled drugs
 Storage and wastage procedures for expired narcotics and controlled drugs
 Reporting discrepancies
 Narcotic Key Replacement
 Location of Spare Keys for Nursing med carts
 See OCP Website for Narcotic Laws:
http://www.ocpinfo.com/client/ocp/OCPHome.nsf/object/
Summary+of+Laws+2005/$file/Prescription+Laws-v2.pdf

e) Prepacking and Manufacturing Trainer______________

There is one full time prepacking technician responsible for the prepacking and manufacturing area. The
pharmacist will be oriented to the duties performed by the Prepacking technicians in order to be able to
check the work of the prepacking technician and locate supplies in the area when required.

 Tour of prepacking/manufacturing area

 MSDS Sheets
 Flammable Cabinet
 Tablet Machine
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 Liquid Machine
 Inhaler tamper seals
 Manufacturing Control Log
 Workload Statistics sheet
 Auxiliary Labels
 Bubble Packaging Machine (view training video on “I” drive)
 Topical Creams/Mixtures
 All compounded items must have final check by pharmacist
 Yellow order to be checked against prescription label ( on new orders)
 All math checked
 All ingredients and expiry dates checked
 All items to have a control number and this must appear on the label
 Sign the compounding log sheet
 Affix appropriate auxiliary labels as required (eg shake well etc)
 Chemicals
 Self Medication Kits
 CV Surgery Pre-op Kits
 Volunteer Activities
 Fume evacuation device (“Smell Sucker”)
 Dishwasher
 Eyewash station – proper use of
 Waste Management Procedures (ie which gargabe goes in which bin)

f) Emergency Department
- Automated Dispensing Cabinet (Accudose) Trainer______________

The Emergency Department has 3 Automated Dispensing Cabinets which contains all wardstock
medication both narcotic and non-narcotic medications. The Accudose cabinets are maintained by
pharmacy technicians; however, the Pharmacist must be familiar with the process and be aware of the
implications for order entry and On-Call

 Accudose Training
 Tour of Emergency Department – Acute, Sub-acute, Clinical Decision Unit, Fast Track, Tracking
boards
 Observe technician filling Accudose
 Stock out lists
 Exception Reports
 Specialty Charges
 Audit trail in patient profile of meds taken from Accudose
 RT boxes
 Fast Track boxes
 Narcotics – cosigning, tracking, discrepancies
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g) Partial Hospital Trainer______________

Partial Hospital patients are psychiatric patients that come into the hospital on a daily basis for social
support and medication monitoring. They are admitted under the nursing station code PAS.
Patient profiles are printed every Tuesday morning and required medications are filled as Outpatient
Charges with a 7 day supply of medication.

 Complete order entry practice exercises for Partial Hospital Patients

 Observe technician filling partial hospital medications
 Checking partial hospital medications

h) Clozapine Trainer______________

The SRHC Schizophrenia Clinic has many clozapine outpatients that receive their drugs free of
charge. These medications are dispensed as outpatient charges and patient profiles are kept for these
patients. Clozapine requires careful blood monitoring and as a result, quantities are restricted to 1 or 2
week supplies depending on the patient. Clozapine is prepared weekly on Wed or Thurs and dispensed
to the clinic for distribution to the patients on Fridays.

 Observe technician doing order entry for clozapine outpatient charges

 Observe technician filling clozapine prescriptions
 Checking clozapine prescriptions

6. Computer Training Trainer______________

 The CIS Help Desk

 Novell Login: first initial followed by last name. Password: first name. To change password do
Ctrl/Alt/Del
 STAR Navigator – Login First initial followed by the first 7 letters of last name. Password: last
name.
 Physician View
 Care Manager
 Trainer to contact Care Manager Team to obtain sign in and passwords.
 Training with floor pharmacist who uses Care Manager Routinely
 ICU Apps
 Emerg Tracking Board
 The “I” Drive, hospital network
 ESI (with Purchasing Technician)
 The Intranet
 Lexi Comp
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 Groupwise – email, appointments, calendar, holiday message

 Palm Pilots
 Computer Generated Medication Schedule (used mostly by cardiology pharmacists)
 STAR downtime procedures

7. IV Room/Sterile Procedures

All Pharmacists will have IV Room/Sterile Procedures training.

 Completed SRHC Pharmacy staff Orientation Checklist for Sterile Preparation

8. TPN

TPN is prepared daily with the exception of week-ends. If patient numbers are less than 7 then TPN is
prepared on Friday for the entire week-end with the exception of MVI and Trace elements which will be
added on Sunday morning. The cut off for new TPN orders is 2 pm. New orders received after that time
will take effect the following day. Plain bags are dispensed until the patient specific additives are done the
following day.

 New TPN orders: Trainer______________

1. Verify dietician is aware of the new TPN order and await changes as needed.
2. Enter TPN and lipids into STAR so they will appear on the MAR
3. Demand an appropriate quantity of TPN and lipids for first day. (enough until 1600 the next
day)
4. Prepare the patient specific TPN worksheet.
5. Using the “Label Maker” create patient specific TPN labels program (procedures posted beside
computer in IV anteroom) .
6. Print a supply of patient specific labels sufficient for several days of TPN treatment.
7. Leave the patient’s TPN order, patient specific labels, demand labels and worksheet together
for the Technician to make a folder.
8. When any TPN changes are made a new worksheet must be prepared.
9. When a TPN is discontinued d/c those TPN labels from the “Label Maker” program.

 New and Daily TPN Floor Pharmacist Responsibilities Trainer______________

1. Bring patient TPN folders to floor in am and assess status of TPN on floor, i.e. volumes of
AA/Dex + lipids remaining.
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2. Review MD orders and dieticians comments regarding relevant blood work, changes to and
progression of TPN; for example, are enteral/ oral feeds commencing soon.
3. Generate appropriate number of demand labels for TPN and lipids (enough until 1600 the
following week-day).
4. Complete TPN worksheet fields for date, bag #, MVI, trace and volume remaining on ward.
5. Return patient TPN folder to pharmacy IV room.

 Checking Pharmacist Trainer______________

1. When IV technician has drawn up additives for TPN, check the following against the TPN
worksheet.
Patient’s name
TPN solution
Additive volumes (eg. correct volume of correct electrolyte solution)
(remember to check that a filter needle has been used for Vit. K)
TPN chambers have been mixed.
Label
Expiration dates
2. Sign TPN Worksheet.

9. Drug Information / DUE Trainer______________

 DI files
 Reference Books in Drug Information Room
 Lexi-online
 Metro-DIS
 Patient Information Sheets
 Nursing Orientation
 Book appointment with hospital librarian for overview of library services and searching
capabilities
 Formulary Addition Requests

10. Purchasing Trainer______________

There is one full time Pharmacy Technician responsible for Purchasing and Receiving. The pharmacist
will be oriented to the duties performed by the Purchasing technicians.

 General Orientation to Purchasing rotation with purchasing technician (1-2hrs)

 Layout and tour of the rolling shelves
 Backorder list
 HealthPro Backorder Web site
 “want” list
 ESI computer system – to look up information
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 Grand and Toy orders

 Receiving/unpacking
 Perpetual Inventory for specific drugs (gases, thrombolytics, GPIIb/IIIa inhibitors)

11. Cancer Clinic Pharmacy Orientation for Non -Oncology Pharmacists

 Tour of Cancer Clinic

 Tour of Satellite Pharmacy
 Location of Fridge Keys
 Patient Profiles
 Blank Protocol sheets
 Clinical Trials Binders
 Gowning/Gloving/Personal Protection requirements
 Cleaning procedures
 Spill Kit location and instructions on use
 Week-end Chemo preparation/checking/dispensing/workload documentation
 Inpatient Chemo Orders – importance of notifying clinic pharmacist ASAP during day or leave
order on chemo cart to go up the next morning
 Weekly Methotrexate orders – enter and leave for clinic pharmacist
 Cancer Care Ontario Website
 BC Cancer Agency Website

12. Workload Documentation Trainer______________

The Guidelines for Management of Information System in Canadian Health Service Organizations (MIS
Guidelines), developed by the Canadian Institute for Health Information (CIHI), provide national
standards for collecting, processing and reporting financial and statistical data on the operation of health
service organizations. The MIS Guidelines address information at the functional centre (department) and
service-recipient (patient) specific level.
At SRHC, the pharmacy reports patient specific (clinical and distribution) workload as well as functional
centre workload. Distribution workload is captured through manual data collection sheets as well as from
computer reports. Clinical and Functional Centre data is collected through documentation into the STAR
system as an “Intervention”. The data collected together with the department’s hours, gives an indication
of productivity that can be compared with other institutions as well as justify staffing requirements.

 Importance and requirement of documenting daily workload

 Read SRHC Pharmacy Clinical Workload Measurement document (describes which activities to
enter under which clinical intervention codes)
 Review Clinical Intervention Codes table (to be printed from STAR Pharmacy by trainer or
Computer Support Technician)
 Overview of distribution and clinical spreadsheets for compiling department statistics (by
Workload Pharmacist of technician) – for information only
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 Overview of spreadsheet submitted to finance department (by Workload Pharmacist or Technician)

– for information only

13. Patient Care Activities: (multiple trainers)

a) General

 Organization of the chart

 Printing patient general worksheet list for floor in STAR
 IV to PO target drugs
 Lab value sheets
 Positive Culture Reports
 General Problem Solving – follow-up of notes left in boxes
 TDM – follow-up and documentation - gentamicin, Vancomycin, phenytoin etc
 Renal Quiz
 Doctor Communication Notes
 Documenting recommendations directly in the chart
 Documentation of clinical activities in patient care record
 Care Manager
 Nursing unit layout
 The Medication Administration Record (MAR)
 Medication Reconciliation
 Medication History
 Clarification of Home Medication
 Medication Reconciliation Preprinted Order
 Observe patient counseling for assigned rotation
 Perform supervised patient counseling for assigned rotation. The trainer may determine when able
to perform counseling unsupervised.
 On call binder (arrange with pharmacy secretary)

b) Floor specific training

 Consult Clinical data sheets for specific floor assignment

c) In addition to the pharmacist’s assigned clinical liaison, all pharmacists need to be familiar with the
programs and general responsibilities of all the pharmacist clinical assignments.

 General Discharge Counseling

 Hip/Knee school (warfarin) – every 2 weeks
 Thoracic School (Lung school) – every 2 weeks
 Cardiac discharge counseling
 CV Surgery discharge Counseling
 Cardiac preop clinic (weekly)
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 The Arthritis Program (TAP)

 Chemotherapy teaching for new patients
 Psychiatric outpatients – weekly lecture
 Heart Function clinic (out-patients) – weekly
 Cardiac Rehab Clinic (out-patients)

14. Administrative

Each new pharmacist will meet with the Pharmacy Manager.

 Sick time procedures

 Overtime log and payroll adjustment sheets
 Continuing Education
 Hospital and Departmental Structure
 Role of the Pharmacy Manager
 Formulary Adherence
 Departmental Meetings

15. Required Reading

 Formulary
 Approved Abbreviations policy (in Nursing Manual On-line)
 Therapeutic Interchange Policy and Procedure
 Document Management Policy (in Admin Manual)
 Guidelines for Developing Preprinted Physician Orders (in Admin Manual)
 Protocols/Guidelines/Medical Directives binder in Order Entry Area
 Administration Manual Table of Contents
 Pharmacy Department Policies and Procedure Manual
 IV Manual – familiarization with
 Infection Control Manual – on intranet
 Hazardous Drugs in the Pharmacy Department – Policy and Procedure
 Latex Allergic/Sensitive Patients – Provision of Medications with natural Rubber Latex Avoidance
(Latex-Smart Environment) Policy
 Latex Allergy Binder
 Pharmacist’s Quick Reference Binder (located in order entry area)
 Physician Handwriting Samples Binder (familiarization with)
 Nursing Manual Online – tablet of contents