Where are the MSDS sheets kept? ✔✔Material Safety Data Sheets (MSDS) can be accessed
immediately online via the web link. Each terminal has this link saved under favorites.
LocalSPRx>Community-Based Specialty> Operational Procedures>MSDS Online. In addition we
can call MSDS in the event of an internet outage.
Can you demonstrate how to access MSDS for 70% Alcohol and 2 drugs? ✔✔Once I log into
StoreNet, we can pull these MSDS up right away. Ensure team members know what to do in the
event of the MSDS link being down. If the link is down, sites utilize the Support office or a
nearby store.
Where is the Hazardous Drug/ Chemoplus Spill kit located? ✔✔Ensure the Spill kit is present
in the pharmacy and located near the compounding area or for non-compounding
pharmacies, near the sink.
,Where is the Eye Wash Station located? ✔✔Ensure the Eye Wash Station is present in the
pharmacy and located near the compounding area or sink, and the plastic wrap is removed.
Where are the cleaning supplies located? ✔✔Show that cleaning supplies are kept under
the sink or in a segregated area away from drugs.
Where is the alcohol spray bottle area
located? Are all spray bottles in their
original manufacturer containers? ✔✔If not, order alcohol spray bottles and keep in
their original manufactured bottle (i.e. not in a generic water spray bottle labeled as alcohol).
ONLY alcohol wipes (not spray) are used when wiping down hazardous counting equipment.
How do you prevent cross-contamination of drugs? ✔✔A separate labeled hazardous drug
counting tray and spatula is used when counting and repackaging individual doses that are not
in unit dose packaging. We wear nitrile gloves when dispensing a hazardous product, and
when required. The counting tray and spatula are cleaned with 70% isopropyl alcohol wipes
after each use. Pill counters and dispensing machines are NOT used for hazardous drugs.
How are hazardous drugs identified in the pharmacy? ✔✔We utilize green mylars (yellow for
p-rated) to
identify hazardous drug in the pharmacy.
What precautions are required when
,handling hazardous drugs? ✔✔It is critical to use separate labeled counting trays and spatulas
for hazardous drug handling. We wear personal protective equipment, as
necessary. Non-sterile hazardous drug compounding is performed at specialized sites under
a powder hood.
How is the equipment used in the
pharmacy cleaned, calibrated, randomly tested, and certified? (i.e. Scales, Pill Counters,
and Hoods) ✔✔All equipment is calibrated daily. Scales are
cleaned on each day of use. Random testing is
done monthly and documented on the
Equipment Log. The log is signed by a
pharmacist at the end of each month to ensure
tasks were completed as the audit. If your site
compounds, speak to the annual certifications of
hoods.
Where are the equipment maintenance
logs kept? ✔✔Show where the logs are kept.
How do you ensure compliance with the Drug Quality and Security Act? ✔✔Medication
is ordered and purchased only
through approved vendors (i.e. licensed
, wholesalers, vendors or direct from themanufactures); suspicious products are reported
to the Security Operations Center (SOC) and
quarantined until disposition direction is
provided.
What would you do if a suspicious drug
was received from the vendor? Such as a product that appears counterfeit, has an
unusual odor, or as a broken seal? ✔✔If we suspect that medication has been
compromised or has become unacceptable for
patient use, we segregate the product. Quarantine the product and report it to the Security
Operations Center (SOC). The RX
Inventory team will then provide direction.
What do you do if the refrigerator or
freezer temperature is out of range?
(Refrigerator temperature range is
between 36-46°F Freezer temperature
should be equal or less than 5°F) ✔✔Document the issue on the TempAlert log, notify
the manager/staff pharmacist, and document action taken to resolve the issue. If
temperature does not return to normal and stabilize after an appropriate period of time, we
would contact the SOC and medication will be moved to an
alternate working refrigerator on Temp Alert and repair service called.
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