Strong Commitment to Staff Safety

July 2020 : Hazardous Drug Handling - Vol. 17 No. 7 - Page #1

Over the past year, pharmacy has demonstrated continuous, committed improvements on the path to full USP <800> compliance. Nearly every metric in our third annual survey showed growth this year, regardless of the delay in enforcement due to the appeal process. While this growth is to be commended, pharmacy must maintain its progress to achieve full compliance despite the newly added pressures of responding to the COVID-19 pandemic.

Survey Design

To monitor pharmacy’s progress in this effort, in the first quarter of 2020, Pharmacy Purchasing & Products polled a random, nationwide sample of health system pharmacy directors. We queried these pharmacy leaders as to their current compliance levels with USP <800> as well as their timelines for achieving full compliance. In addition, we asked about HD policies and procedures, staff training, wipe sampling practices, and more. Responses were solicited via email and a total of 315 pharmacy leaders replied, yielding a confidence interval of 5.37 (95% +/-5.37).

We intentionally survey a random sample of pharmacy directors, not just readers of PP&P, to ensure the data reflects trends across the entirety of US hospital pharmacy practice. Given this approach, we are pleased that 93% of pharmacy directors rely on PP&P as a resource for HD handling information.

More than nine out of every 10 health systems rely on PP&P to serve as a resource for compounding compliance.


Progress Worth Celebrating

This year, compliance to PPE usage became nearly universal and risk acknowledgement forms are regularly provided to HD compounding staff. Most facilities have segregated HD storage, typically within neutral or negative pressure rooms, while also utilizing dedicated refrigerators for HDs. While PEC placement has been a challenge in the past, the vast majority of facilities now externally vent their CPECs for sterile HD compounding while also continuously monitoring the cleanroom’s air pressure. Improvements have also been seen in HD tracking capabilities for recall purposes.

Areas for Improvement

Some areas of HD compounding remain quite challenging for pharmacy, underscoring the need for further guidance. Nonsterile HD compounding is one area where many facilities struggle to complete an SOP. Likewise, the creation of a medical surveillance program, which requires significant collaboration with outside parties, continues to stymie many pharmacy leaders.

While pharmacy’s commitment to staff safety is laudable, all too often that commitment does not extend beyond the pharmacy. Receiving areas, for example, rarely benefit from established monitoring processes, such as wipe sampling to determine if products arrive already contaminated, or spill drills, which ensure staff can safely respond to the inevitable spill. Similarly, SOPs for CSTDs are typically established in the pharmacy, but are less likely to exist for HD administration. It is crucial that pharmacy’s leadership role in safe HD handling encompass every staff member who encounters HDs, not just those in the pharmacy department.

PP&P will continue to support your efforts by sharing the success stories of your peers. Take the opportunity when constructing new cleanrooms, designing new workflows, and writing new policies and procedures to exceed the standards and utilize best practices.

Deanne Halvorsen is the editorial director of Ridgewood Medical Media, publisher of Pharmacy Purchasing & Products and MedicalLab Management. She can be reached at


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