Compounding Sterile Products (USP 797)
This is how often the laminar flow hood and BSC are cleaned.
What is once per shift?
The Corporate Compliance Officer for SBUH.
Who is Lori Strauss?
This program is used to access all SBUH/SBSH policies.
What is PolicyTech?
This acronym is used to identify high-alert drugs at SBUH.
Bonus*: This acronym is used to identify high-alert drugs at SBSH.
What is ACLIPS?
A- Anti-coagulants
C- Calcium (excluding parenteral nutrition)
L- Lanoxin
I- Insulin
P- Potassium
S- (Hypertonic) Saline
Bonus*
What is HIPPOS?
H- Heparin and anticoagulants
I Insulin
P Potassium and Pitocin
O Opioids
S (Hypertonic) Saline
Give an example of what NOT to say to a surveyor.
"I don't have time for this."
"I don't know."
Generally anything rude or dismissive.
Describe the proper process for donning PPE before entering the clean room.
1. Remove jewelry, artificial nails, etc.
2. Don head and facial covers
3. Don shoe covers
4. Wash hands (30 seconds to elbows)
5. Don non-shedding gown
6. Cleanse hands with alcohol-based hand sanitizer
7. Don sterile gloves and ensure there are no defects
The maximum amount of time a wheeled item is allowed in a corridor.
What is 30 minutes?
R.A.C.E.
What is R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
Name four criteria required for a complete chemotherapy order.
Complete chemotherapy orders include:
i. Patient’s full name and medical record number
ii. Date
iii. Diagnosis
iv. Regimen name and cycle number (if applicable)
v. Appropriate criteria to treat (laboratory values)
vi. Reference to the methodology of the dose calculation or standard
practice equations (e.g., calculation of creatinine clearance)
vii. Height, weight, and any other variables used to calculate the dose
viii. Dosage
ix. Route and rate (if applicable) of administration
x. Length of infusion (if applicable)
xi. Supportive care treatments appropriate for the regimen
The length of time you must flush your eyes at an eyewash station after contamination.
What is 15 minutes?
These are the components of a clean room.
What is a primary engineering control (PEC) and secondary engineering control (SEC).
Describe the process for monitoring the eyewash stations.
Bump test performed weekly.
Record temp of water by pouring water in a beaker and using an infrared thermometer (weekly). What is the appropriate temperature range of the water?
Record both results on log.
P.A.S.S
P- Pull the pin A-Aim the nozzle at the base of the fire, S-Squeeze the handle, S-Sweep the nozzle from side to side
These two individuals perform a double check of a final chemotherapy preparation.
Who are a Pharmacist and nurse that is not involved in patient's care? (Independent check)
This was the topic of SBM's 2020 Failure Mode Effects Analysis.
What is Failure to Rescue?
6 hours in an ISO-5 or greater environment, 1 hour outside of ISO-5 or greater environment.
P1. This is the most important step in infection prevention.
P2. This is the PPE we wear when we are in the vicinity of patients.
A1. What is handwashing?
A2. What are a mask and eye protection?
These are the 2 patient identifiers.
What are Name and DOB?
These strategies are used to identify LASA drugs
What are tallman lettering and signage
The general length of time between Joint Commission surverys.
What is 3 years?
Name the major difference between a laminar flow hood and biological safety cabinet.
What is positive vs. negative pressure
This is where you can find the manuacturer's Instructions for Use.
What is OneSource?
This system is used to report all adverse drug events.
What is SB Safe?
This is the location outside the Pharmacy where medication is stored in case of an emergency.
The differences between an Failure Mode & Effects Analyasis (FMEA) and an RCA (Root Cause Analysis).
FMEA - Analysis of a high risk process before it becomes a problem of affects a patient. (Prospective)
RCA - Analysis of a previous event to determine the cause and implement changes to prevent a repeat incident. (Retrospective)