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Outside of pharmacy, there are many opportunities for improvement. Nursing staff who are compounding/preparing medications on the floor are generally not receiving the proper training from pharmacy. Furthermore, of the few who are trained and required to do annual media fills to verify their aseptic training, only 35% have a zero contamination rate. An additional area of opportunity for pharmacy is collaboration with the risk management department, as only 20% report meeting with risk management to get the resources necessary to comply with <797>.
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