Growing Compliance

July 2022 : Hazardous Drug Handling - Vol.19 No. 7 - Page #1

Pharmacy’s strong commitment to safe hazardous drug (HD) handling practices is reflected in the growing number of facilities achieving full compliance to USP <800>. This increase in compliance efforts is important, as state board of pharmacy inspections are expected to bring a stronger focus to HD practices in the coming year.

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 2022. 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 201 pharmacy leaders replied, yielding a confidence interval of 6.74% (95% +/-6.74). Respondents’ facility sizes range across the spectrum, from smaller hospitals to large health systems.

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 89% of pharmacy directors rely on PP&P as a resource for HD handling information.

We are pleased to note that 89% of pharmacy leaders rely on PP&P as a resource for HD information.

Reasons to Celebrate

Pharmacy’s ongoing attention to facility design in particular is paying dividends, as most facilities now utilize properly vented cleanrooms and storage rooms complete with automated pressure monitoring and dedicated refrigerators to support safe HD compounding. Likewise, SOP development continues apace with most facilities having delineated the expectations for practices, ranging from hand hygiene and decontamination to transport and spill control.

Opportunities abound for streamlining HD practices; for example, consider utilizing SOP management software to simplify the updating, documentation, and distribution processes for your HD policies. This software can be particularly helpful during an audit. Likewise, conducting risk assessments for certain Group 2 and 3 HDs can improve workflows and deliver cost savings.

Beyond Pharmacy

Too often HD policies focus on the pharmacy department to the exclusion of other hospital areas. To counteract this problem, HD policies must address the safety of all staff working with HDs, including those in receiving, nursing, environmental services, and the OR. Also, consider impacts on students, residents, traveling nurses, and other nontraditional staff.

Our survey results show that while CSTD implementation is almost universal in the cleanroom, adoption rates are lower on the nursing units administering HDs. In addition, most wipe sampling is focused on the cleanroom or HD storage area; it occurs infrequently on nursing units. Mock spills are another example of a practice that is more likely to be conducted in the pharmacy, making it impossible to evaluate spill responses in other areas. The annual SOP review is an excellent time to ensure HD protocols encompass areas beyond the pharmacy.

Standards only become more stringent over time, so build your program with an eye toward the future—identifying opportunities to exceed the current minimum requirements will support your future success.

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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