Volume 2025 | No. 2
SURVEYOR
PHARMACY
Cleaning/disinfection practices: ■ There is currently no log for pharmacy cleaning. ■ The pharmacy has a cleaning schedule and log, however the cleaning and disinfection processes documented do not include: ٝ The cleaning or disinfection agent used. ٝ Who performed the daily cleaning. ٝ Cleaning of counting trays for both HD and non-HD. ■ Cleaning products were expired. Compliance tips for:
Compliance tips continued:
■ Check all locations where drugs are stored, including (but not limited to) will-call/pick-up areas, locked cabinets, carts, and warehouse space. Ensure that all medications are: ٝ Stored in areas that are monitored for temperature and humidity. ٝ Accessible only to applicable licensed staff. ■ Routinely verify that all temperature sensing devices are calibrated in conformance to NIST standards. ■ Audit cleaning and disinfection logs and confirm documentation of when the cleaning occurred, what was cleaned, who performed the cleaning, and the cleaning or disinfection agent used.
Nerd Apprentices (audit for excellence)
■ This standard includes several elements addressing storage processes, cleaning logs, and contingency plans. The overall goal is to maintain efficacy and ensure safety for all stored pharmaceuticals. ■ Pharmaceutical storage is accessed only by authorized personnel and maintained within the proper temperature and humidity, as specified in USP <659> and the manufacturer’s guidelines. ■ Storage requirements for an ambulatory infusion center/suite are different than those for specialty and infusion pharmacy. For example, if emergency medications are stored in the infusion rooms within a locked cabinet or medication cart, then the infusion room needs to be temperature- monitored. ■ Every drug storage location should be consistently inventoried, monitored for temperature and humidity, cleaned, and disinfected. If this isn’t possible, pharmaceuticals must be relocated to an appropriate storage location. ■ Manufacturer’s instructions and USP <659> requirements must be adhered to for the acceptable temperature range and humidity. ■ Manufacturer’s instructions and USP <797> requirements must be adhered to for cleaning frequency, cleaning agents, dwell time, and the calibration of the equipment.
■ Educate staff on:
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
ٝ .The importance of temperature monitoring. ٝ How to handle and document excursions. Cover appropriate corrective actions for various situations, ranging from a simple power outage to a more complex scenario requiring the movement of inventory to another location.
■ Develop a contingency plan that addresses situations when: ٝ Storage conditions fall outside of established ranges. ٝ The excursion continues for an extended period of time.
ٝ The excursion is affecting multiple storage areas for an extended period of time.
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