Category: Federal Forum Posters
Purpose: The U.S. Pharmacopeial Convention published Chapter 800 in February 2016. It sets standards for handling of hazardous drugs in healthcare settings and will be legally enforceable by December 1, 2019. There has been lots of conversation regarding preparation in the hospital and inpatient areas of Pharmacy, but not much specific to an outpatient pharmacy setting. These standards will be enforceable by the FDA, state pharmacy boards, Joint Commission and CMS. This makes understanding what they entail in an outpatient pharmacy of vital importance.
Methods: An Ambulatory Care Outpatient Pharmacist was chosen as the designated person and assigned as the Institutional Leader for USP 800. An initial Gap Analysis was conducted for 7 Ambulatory Outpatient Care pharmacies associated with the Academic Center to assess awareness and readiness. Based on those results, steps were taken for appropriate department awareness. Initial steps were taken to provide education to the Ambulatory Care Outpatient Pharmacies. USP 800 champions were selected from each respective pharmacy and education was provided on appropriate receiving, storage, and handling of hazardous drugs. Environmental Health Services and Facilities Management was involved to provide consultation and assess for any structural changes necessary in the Pharmacies, specifically to receiving and storage areas within the pharmacies. An assessment of risk template was created and completed based on the NIOSH list of hazardous drugs. Updates to Policies and Procedures is ongoing based on pending changes.
Results: All pharmacy staff was educated through department meetings, in-services, and face-to-face pharmacy huddles about upcoming changes in receiving, storage, and handling of hazardous drugs. Staff was further educated about the importance of assessment of risk forms for all hazardous drugs, including different dosage forms of the same drug. Pharmacy managers were educated first to facilitate team buy-in and then primary staff involved in receiving and storage was further educated to ensure understanding. In-services were provided to the entire department with support from Pharmacy Administration to further ensure buy-in from the entire department staff. After department wide in-services were given, each pharmacy was visited by the USP 800 designated person and staff members received one-on-one education with live demonstration. This lessened the anxiety of staff regarding upcoming changes and resulted in more overall buy-in. Sample assessment of risk forms were completed and shared with pharmacy team members to demonstrate all required steps in handling of hazardous drugs and provide a visual.
Conclusion: This method ensures that outpatient pharmacies receive the needed and required education on USP 800 in a timely and efficient manner. Support from Pharmacy Administration and Pharmacy Managers lead to overall more buy-in from Pharmacy staff. More buy-in from staff will lead to increased compliance, decreased anxiety regarding changes, and a heightened awareness of employee safety. The comprehensive one-on-one training to complete tasks according to USP 800 standards lead to a better understanding of how to implement such standards within each respective pharmacy and ensure compliance with new pharmacy policies and procedures.
Monazzah Sarwar– Assistant Director/Assistant Professor, University of Illinois at Chicago, Chicago, IL