Compliance is Necessary Now

July 2021 : HD Handling - Vol.18 No. 7 - Page #1
Category: USP Training Programs

The date on which USP <800> becomes official remains ambiguous; however, that is not the case with state board enforcement. A growing number of state boards of pharmacy expect compliance with the chapter, and inspectors are well-versed in the requirements. Even if your state has yet to require compliance, the regulations in the chapter outline best practices to ensure hazardous drug (HD) safety, and should be adopted forthwith. Furthermore, given that standards become more stringent over time, adopting the current standards while looking for other opportunities to improve safety will only benefit the pharmacy.

Survey Design

To monitor pharmacy’s progress in safe HD handling, Pharmacy Purchasing & Products polled a random, nationwide sample of health system pharmacy directors in the second quarter of 2021. We queried these pharmacy leaders as to their current compliance levels with USP <800>, as well as their timelines for achieving full compliance. Responses were solicited via email and a total of 299 pharmacy leaders replied, yielding a confidence interval of 5.42 (95% +/-5.42).

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 92% of pharmacy directors rely on PP&P as a resource for HD handling information.

A substantial 92% of pharmacy directors rely on PP&P as a resource for HD handling information.

Pharmacy’s Marked Progress

In a year where stalled progress in areas outside of COVID responses would be forgiven, pharmacy has taken the opposite tack. For many facilities, improving HD handling practices continued apace this year despite the challenges driven by the pandemic. Key areas of improvement included further development of SOPs, the use of respirators, and the distribution of risk acknowledgement forms.

Likewise, pharmacy demonstrated a strong commitment to HD list development and management this year, but rare are the facilities that include any drugs on the list beyond those on the NIOSH list, and progress is needed in the number of facilities that include a severity classification for each HD and the route of administration.

That said, increasing numbers of dedicated refrigerators, pressure indicators, wipe analysis kits, and spill kits were purchased this year, and there was a similar increase in the number of facilities conducting wipe analyses and spill drills. These safety efforts continue to focus on pharmacy locations, underscoring the need to expand these practices to receiving and patient care areas.

Accessible Compliance Resources

Your cleanroom certifier can serve as an excellent resource, from identifying sources of risk to sharing best practices implemented at other facilities. Schedule sufficient time to meet with your certifier to review their report in detail and use this time to further your own education.

To this end, PP&P continues to provide excellent content in support of your compliance efforts, be it through informative articles (searchable at, help in identifying reliable vendors (our vetted vendor database is at, as well as expert led webinars ( that address the same compounding challenges that you are wrestling with.

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

2021 Hazardous Drug Handling Slides


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