(IV) Medications - Compounded Sterile Preparations - UNM Cancer ...

1. Documented CompetencyAll personnel who prepare sterile preparations must have documented annual competency to doso.2. Ensure Proper aseptic technique3. Designated AreasEating, drinking and the storage of food are prohibited in the area designated for sterile productpreparation.4. InspectionAll bottles are inspected for particulate matter, cracks and the manufacturer’s expiration date. AIV bag is inspected for leaks and particulate matter before and after admixture is made. Anyquestionable product is discarded.5. Additive Ports and Vial TopsAdditive ports and vials tops and IV containers are wiped with sterile 70% isopropyl alcohol(IPA) sponges (swabs) prior to performing admixtures. Swab must be wet and not overused.Minimally, a new swab is used on each additive container (bags or vials).6. Touch ContaminationTouch contamination of syringe tips, needles, stopper and injection ports is avoided.7. Medication Vials and Containers The person preparing the medication is responsible for labeling the medication. All medications drawn up or prepared, including those prepared from multi-dose vials, will beappropriately labeled before being taken to the patient. Medication or solution labels will include the patient’s name, medical record number, medicationname, strength, amount (if not apparent from container), initials of person preparing admixture,and the exact one-hour beyond use date.Single-dose containers shall be used within one hour after opening or needle-punctured andremaining contents properly discarded. Multi-dose vials contain an antimicrobial preservativewhich may be used for 28 days and should be initialed and dated when opened.Preparation Procedure:Non-pharmacy personnel are authorized to prepare immediate-use CSP’s only inurgent/emergent situations or when the product stability precludes pharmacy preparation. Theymust have successfully completed the Online Competency of compounded sterile preparationsfor non-pharmacy personnel.A. Pre-Procedure Steps1. Check the physician orders.2. Assemble all equipment and supplies needed in a designated work area, free of traffic,preferably an isolated area3. Assure that the designated area is clean4. Complete the appropriate label to include:a. Patient’s name, location, and medical record numberb. Name of drug, amount of drug, name of basic parenteral solution and solution volumec. Date and time of the addition5. If there are any questions of compatibility of medications check with resources availableand/or call PharmacyB. Drawing up of a single entity medication into a syringe1. Swab the diaphragm or stopper of the vial with sterile IPA and allow drying.2. Draw up correct amount of medication.3. Label syringe and administer.C. Admixture Reconstitution Procedure_________________________________________________________________________________________________________________Title: Intravenous (IV) Medications - Compounded Sterile Preparations (CSPs)Owner: Director, PharmacyEffective Date: 7/21/2009Doc. #2524Page 2 of 4