Compounding Sterile Products (USP 797)
Potpourri
Patient Safety/EOC
Medication Management
Joint Commission Basics/Common knowledge
100

This is how often the laminar flow hood and BSC are cleaned.

What is once per shift?

100

The Corporate Compliance Officer for SBUH.

Who is Lori Strauss?

100

This program is used to access all SBUH/SBSH policies.

What is PolicyTech?

100

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

100

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.

200

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

200

The maximum amount of time a wheeled item is allowed in a corridor.

What is 30 minutes?

200

R.A.C.E.

What is R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish

200

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

200

The length of time you must flush your eyes at an eyewash station after contamination.

What is 15 minutes?

300

These are the components of a clean room.

What is a primary engineering control (PEC) and secondary engineering control (SEC).

300

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.

300

P.A.S.S

What is -

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

300

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)

300

This was the topic of SBM's 2020 Failure Mode Effects Analysis.

What is Failure to Rescue?

400
If it is necessary to re-use a single-dose vial, this is it's Beyond-Use Date.

6 hours in an ISO-5 or greater environment, 1 hour outside of ISO-5 or greater environment.

400

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?

400

These are the 2 patient identifiers.

What are Name and DOB?

400

These strategies are used to identify LASA drugs

What are tallman lettering and signage

400

The general length of time between Joint Commission surverys.

What is 3 years?

500

Name the major difference between a laminar flow hood and biological safety cabinet.

What is positive vs. negative pressure

500

This is where you can find the manuacturer's Instructions for Use.

What is OneSource?

500

This system is used to report all adverse drug events.

What is SB Safe?

500

This is the location outside the Pharmacy where medication is stored in case of an emergency.

What is Level-1 Radiology?
500

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)