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Pharmacy Sterile Compounding

March 15, 2019

Hospital Pharmacy Departments in Ontario now undergo regular inspections by the Ontario College of Pharmacists. A key area of these inspections has been ensuring hospital pharmacy departments are preparing sterile compounded medications according to national standards.

Sterile compounds are medications that are prepared for use as injections. When medications are given as injections, many of the body's abilities to defend against contamination are bypassed, making these medications extremely important to be free of contamination.

To meet standards pharmacy staff have been completing extensive online training as well as practical tests that ensure staff can put on sterile gloves and perform a series of complex manipulations without introducing contamination. Michelle, Lead Compounding Technician says, “These new standards have created a major change to the dynamics of our intravenous medication preparation and chemotherapy program. Additional training and education has to be completed and challenges to the Pharmacy workflow have been identified. The Pharmacy Team have been working diligently to incorporate all of these standards into daily practice while maintaining the priority of patient care and have done a fantastic job of adjusting to these new initiatives to ensure we are providing compounded products of utmost sterility.”

Michelle, Lead Compounding Technician

The pharmacy has also undergone significant process changes to meet standards and have received support in these changes from a number of other departments including: IT, facilities management, infection control, materials management, quality and risk, chemotherapy and housekeeping.

Housekeeping staff, in particular, play a significant role in ensuring we meet standards by cleaning the compound rooms using the appropriate products and frequency. “The housekeeping team always rises to every challenge with positive attitudes,” says Brenda Smellie, Director Housekeeping & Linen. “The two day training was rewarding as we learned how to meet the new pharmacy standards.”

Housekeeping Staff during training

Once all of the training and process changes have been completed our next milestone on our path to full compliance will be building a physical environment that meets standards. This will require redevelopment of the pharmacy department which is expected to take place in approximately two years. “A new department will not only allow us to meet compounding standards but help address many of the workflow challenges our team faces on a day-to-day basis in our current space,” adds Michelle.