Volume 2024 | No. 2
SURVEYOR
PCAB COMPOUNDING
Tips for compliance:
n Train and critically observe all personnel performing hand washing, gowning, and gloving. Ensure that the sterility of the hands and gloves is uncompromised throughout the compounding process. Avoid placing the gloved hands in or on the waste receptacle. n All personnel should know how to appropriately stage supplies into the compounding area so as not to impede the compounding process or block first air, including wiping them with sIPA or an EPA-registered disinfectant agent whenever they are transferred from a less sterile ISO environment to a more sterile ISO environment and when introducing them into the direct compounding area. n Educate staff on aseptic technique and proper hand placement for the various types of hoods (e.g., vertical, horizontal) used in the pharmacy to ensure first air is not blocked. n Ensure all compounding stages have checks and rechecks. n All personnel must understand how to use equipment, even something as fundamental as a syringe. n Clean in a manner that does not potentially introduce contamination from outside of the LAFW into the compounding area of the LAFW. n A sterile cleaning and disinfecting agent(s) must be used when cleaning inside the PEC. n Establish a process to ensure bulk vials of medications are reconstituted appropriately before their use in CSPs. It may be helpful to ask the hood certifier to make a second recording of the dynamic airflow smoke study, but on the second recording, intentionally interrupt the first air in the horizontal and vertical hood so the technician can visualize the impact of first air interruption.
PHARMACY ACCREDITATION
Services
Distinctions
Ambulatory Infusion Center Community Retail Infusion Nursing Infusion Pharmacy Long-Term Care Pharmacy
Infectious Disease Specific to HIV Nutrition Support Oncology Rare Diseases and Orphan Drugs Telehealth
Mail Order Pharmacy Specialty Pharmacy Specialty Pharmacy without DMEPOS
FREQUENT DEFICIENCIES IN PHARMACIES
60%
50%
40%
30%
20%
10%
0%
DRX1-4A DRX2-4C
DRX4-7A
DRX5-1A
DRX5-2B
DRX5-2C
DRX7-5B
DRX7-9A
DRX7-9B
Organization and Administration
Provision of Care and Record Management
Program/Service Operations
Human Resource Management
Risk Management: Infection and Safety Control
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