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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 the
manufactures); 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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