Compounding Institutional
Drug Concentrations Expression of a Solid Mixture "Grams
"Grams of drug" per "100 grams" or "g/100 g" Referred to as "weight per weight" or "w/w" Example: Hydrocortisone 2.5% ointment 2.5 grams of hydrocortisone in 100 grams of ointment or 2.5 g/100 g
Drug Concentrations Expression of a Solid Solution or Suspension
"Grams of drug" per "100 milliliters" or "g/100 mL" Referred to as "weight per volume" or "w/v" Example: Dextrose 5% solution 5 grams of solid dextrose dissolved in each 100 milliliters of solution or 5 g/100 mL
Drug Concentrations Expression of a Liquid Mixture
"Milliliters of drug" per "100 milliliters" or "mL/100 mL" Referred to as "volume per volume" or "v/v" Example: 70% ethanol solution 70 milliliters of ethanol in 100 milliliters of total solution or 70 mL/100 mL
Syringe Choice
"Next size up" rule of thumb: Use the SMALLEST syringe possible that holds MORE than the required dosage amount If the syringe is too large, it can result in inaccurate measurements If the syringe is too small, it can result in needing multiple syringes and lead to waste If the syringe holds the exact volume you need, fluid could spill out if the plunger is pulled all the way back in the barrel
Practice Problems Formula for Increasing/Decreasing Compounding Formula
# of ml (or g) you want # of mL (or g) formula yields
Non-Sterile Compounding
- All ingredients and containers must be properly labeled - Quality control programs must be implemented by the pharmacist - Labels must include the quantity and lot number - Products must be assigned a correct beyond-use date Documentation must be correctly filled out • Patients must receive pharmacist consultation on proper administration and storage compounded product
Sterile Compounding: Safety Precautions Proper Disposal All used
All used needles must be disposed of in a sharps container Red sharps containers are for nonhazardous sterile compounding waste
Equipment Class III Torsion Balance
Also known as a Class A torsion balance Type of two-pan balance Required by most state laws Measures weights 15 to 120 grams No less than 120 mg should be weighed • Sensitivity requirement is +/- 6 mg
Personal Protective Equipment (PPE) Description
Also known as sterile garb Covers hair, face, nose, ears, arms, hands, clothing, and shoes Protects the compounder from exposure to medication Prevents contamination of sterile products
Key Sterile Compounding: Supplies and Equipment IV Bags IV Piggybacks (IVPBS)
An IV that is "piggybacked" on the patient's main IV line Usually used to dilute medications Usually used for antibiotics, antifungals, and mineral replacements
Chemotherapy Preparation Chemotherapy Equipment & Supplies Chemotherapy Spill Mat
An absorbable mat placed on the part of the workbench where the compounder will be working in the flow hood Made of an absorbable material to soak up any spilled chemotherapy Dispose of mat in chemotherapy sharps container when finished
Parenteral Dosage Forms
Any drug or fluid that is injected into the body, usually through a needle Gl tract is avoided Medications usually act more rapidly than oral drugs Product must be sterile and prepared by "aseptic technique" More difficult to remove from the body than oral meds
Communication During Medication Reconciliation If Verbal Communication
Ask open-ended questions Helps the patient understand your question and recall specific facts Speak with a normal volume and rate of speech
Cleaning the Laminar Flow Hood When to Clean
At the beginning of every shift Before beginning a batch compound After every 30 minutes of continuous compounding When the flow hood is visibly dirty or if there's a spill
Automation: Institutional Bar Codes Purpose
Automate dispensing and administration of meds Track inventory Order stock Fill orders Verify correct drug Reduce medication errors Ensures correct bar-coded medication administration (BCMA)
Hospital Medication Preparation Auxillary Labels Overview Information
Information thatis meantfor medical staff Should be in highly visible position on the IV bag, syringe, or zip-top bag • Are usually colored so they stand out from other labels - Do not rely on the color of the auxiliary label (different suppliers may use different colors) Read the auxiliary label before applying to ensure you're using the right one for the med being dispensed
Infusion Calculations Infusion Time Definition
Infusion time calculations are useful in finding the amount of time that it takes for a specified amount of solution to be administered to a patient.
Parenteral Dosage Forms Intradermal (ID) Medications Parenteral
Injected between upper layers of skin, usually in arm or back Require tiny needle to lessen discomfort and pain • Examples Fluzone Intradermal flu vaccine Tuberculosis diagnostic test - Allergy tests
Lyophilized Powders Reconstituting
Lyophilized powder must be liquified with proper diluent and amount before dispensing Look at vial's drug label or package insert for correct diluent and amount of diluent to use
Non-Sterile Compounding Food and Drug Administration Modernization Act of 1997
Made it allowable for pharmacists to compound non-sterile products for individual patients USP <795> guidelines were created to control good compounding practices that must follow Chapter Staff members must be educated and trained Compounders must wear protective clothing Equipment must be cleaned and calibrated Each step in the preparation process must be reviewed Final check is done by a pharmacist
Non-Sterile Compounding Equipment Ointment Slabs
Made of a nonporous surface, e.g., glass Used to mix ointments or creams on Allows for an easier clean up
KP Sterile Key Compounding: Supplies and Equipment Ampules
Made of thin glass Useful for medications that are incompatible with a vial's rubber stopper, plastic, or other chemicals found in vials Must be discarded after first use
Sterile Compounding: Supplies and Equipment Large Volume Parenterals (LVPS)
Mainly used to rehydrate the patient and give essential nutrients May contain medication as well Can include medications needed for around-the-clock therapy
Preparation of Sterile Compounds Compounding Process Piercing The Vial's Rubber Make Stopper
Make sure to wait 10 seconds after cleaning the vial with an alcohol pad to pierce the vial This will ensure the rubber stopper is sterilized before piercing Hold the vial steady with your non-dominant hand and use a 45-to-90-degree insertion method, with bevel side up, when inserting a needle into the vial's rubber stopper Prevents the rubber stopper breaking off into the solution (coring)
Preparation of Sterile Compounds Alternative Preparations Premade IV Piggyback Bags
Manufacturer places the medication in an IV bag No need to sterile compound Many common antibiotics come this way Some require special storage Check IV bags labeling for storage information
Infusion Calculations Common IV Sets Manufacturers
Manufacturers make IV sets that have different sized drops Identified as number of drops it takes to make 1 mL (also called drop factor) Common examples include 10, 15, 20, and 60 gtt/mL IV sets 10, 15, 20 drop sets are also called macrodrops sets 60 drop sets are also called micro, or mini-drip, sets
Compounding Key Terms "QSAD"
Means add sufficient quantity to make
Hospital Medication Preparation Medication Order Labels Required Information
Med order labels must contain: The patient's name, date of birth, and ID number (to identify the patient) The patient's room number (where the patientis located in the hospital) The prescriber's name The pharmacy's name The med's name, strength, and quantity Directions for use The med's due date/time (when medication is to be given/administered) When the medication expires IV flow rate (if the medication is in an IV bag) Your initials (if required by hospital policy or state law) Don't fill a med order with a label that is missing information and contact the pharmacist
Sterile Compounding: Supplies and Equipment Y-Site Compatibility
Medical device that merges two IV lines into one
Medication Reconciliation Types Of Medication Errors Incorrect Doses
Occurs when the patient is given too much, or too little, medication Patient can experience more side effects if dose is too high, or their condition can treated if dose is too low
Medication Reconciliation (Med Rec) Overview Types Of Medication Errors Duplications
Occurs when the patient is prescribed a new strength of a medication, and the old one isn't discontinued Patient ends up taking both strengths of medication Can lead to overdose of medication Error often occurs during transitions of care
The Laminar Flow Hood Filters
Prefilter Captures dirty air before it hits HEPA filter Needs to be changed monthly HEPA filter Removes almost all bacteria, fungi, and viruses from the air before it reaches the compound Is inspected and changed every six months (biannually or semiannually)
Categories of Products Simple
Preparations that have a USP monograph or appear in a peer-reviewed journal with specific quantities, procedures, equipment, and stability information Includes reconstituting or manipulating commercially available products by adding more ingredients to them
Categories of Products Moderate
Preparations that require special calculations or procedures to measure quantities Includes making preparations that don't have stability data available
Non-Sterile Compounding After thatdnle Beyond-Use Dating Water-Containing Formulations
Prepared from solid ingredients Have a beyond-use date of no later than 14 days, even when stored at cold temperature
Medication Order Delivery Computerized Prescriber Order Entry (CPOE) Advantages
Prescriber uses computerized software to send the medication order to the pharmacy Advantages over fax and verbal orders include: No need to decipher bad handwriting Sent instantly from the prescriber Helps billing of medications Allows prescribers to check for interactions and allergies at the point of inputting
Automated Dispensing Cabinets (ADCS) Steps to Refill an Automated Print Dispensing Cabinet Click
Print refill report Click the name of the drug to refill on the machine's screen Count the number of existing packages in the machine • Verify the beginning count in the system Enter the medication's expiration date Place medication packages in the machine
Non-Sterile Compounding Blending Techniques Tumbling
Process of combing two hazardous powders together by using a resealable bag or bottle Mix by rotating or "tumbling" the bag or bottle
Non-Sterile Compounding Blending Techniques Sifting
Process of combining two powders together, like sifting flour for baking
Medication Reconciliation (Med Rec) Overview What is a Medication Reconciliation?
Process of gathering a list of all the patient's current medications Include prescriptions, OTCS, herbais, and dietary supplements that the patient takes List is compared against any new medication orders to ensure no duplications Hospital pharmacy technicians can specialize in this field
Non-Sterile Compounding Comminution Techniques Levigation
Process of reducing particle size of a solid when combining it with a cream or an ointment Add a levigating agent to the insoluble, or unable to dissolve, solid The levigating agent and solid become a paste to combine with the cream or ointment Common levigating agents are castor oil, glycerin, and mineral oil
Automated Dispensing Cabinets (ADCS) Benefits
Provides nurses with direct access to medications in patient care areas Decreases time to get meds to patients Increases security
Non-Sterile Compounding Recordkeeping Compounding Record
Similar to the prescription information kept on file, it includes Name and strength of the compounded preparation Formulation record reference for the compounded preparation Sources and lot numbers of ingredients used Actual quantities measured/weighed - Number of dosage units, or quantity, compounded Name of the person who prepared the compound - Date of preparation Internal identification number or prescription number Beyond-use date
Compounding Calculations Practice Problems How to Decrease the Compounding Formula Example (continued)
To figure out how much to decrease each ingredient, you'll divide the total number of grams you want by the total number of grams the formula yields. # grams you want = 30 g = 1 = 0.25 # grams formula yields 120 g 4 You'll multiply each ingredient quantity by 0.25. Coal tar 3 g x 0.25 = 0.75 g Salicylic acid 2 g x 0.25 = 0.5 g Triamcinolone 1% cream 15 gx 0.25 = 3.75 g Eucerin cream 100 g x 0.25 = 25 g Yields 120 g x 0.25 = 30
Alligations
To mix 2 ingredients with different concentrations to get an intermediate-strengen product
Sterile Compounding: Supplies and Equipment Ampules Opening and To open Manipulation
To open an ampule, place your dominant hand's fingers on top of the ampule and your non-dominant hand's fingers on the bottom Don't touch the ampule's neck because it may break into jagged glass. Break ampule towards side wall of the hood Prevents shards of glass from damaging the HEPA filter Use a filter needle to withdrawal fluid from opened ampule Removes glass from solution
IV Bags Base Solutions
Dilutes medications Used for hydration and electrolyte replacement
Hospital Medication Preparation Labeling Medications IV Bags
Do not coverany important information on the bag Place the label on the back, clear side of the IV bag (may be required by your pharmacy)
Crash Boxes Technician's Role Record Expiration Dates of Crash Box Medications
Document the earliest expiration date for each set of meds stocked in the crash box Circle the earliest expiration date on the form
Preparation of Sterile Compounds Sterile Compounding Precautions Drug Spills
Don't clean the spill without looking at the safety data sheet (SDS) for proper cleanup • Inform supervisor about the spill
Chemotherapy Preparation Points Recap Chemotherapy Compounding Procedures Syringe Filling Rule
Don't fill the syringe with more than 75% of chemotherapy medication Choose a larger-sized syringe if the volume of the syringe will exceed 75%
Non-Sterile Compounding Compounding Area
Don't need a sterile environment or flow hood Area should always be cleaned before and after compounding a product
Chemotherapy Preparation Chemotherapy Compounding Procedures Shadowing
Don't shadow critical sites from above or below, since air is vertical in a chemotherapy flow hood
Non-Sterile Compounding Points Recap Equipment
Don't use for thick liquids
Preparation of Sterile Compounds Recap Compounding Process Filling Syringe With Air
Draw back and inject the same amount of air as fluid you need Adding positive pressure to vial prevents fluid from being injected back into the vial
Drug Concentrations Practice Problems
Express this drug's concentration as a fraction: fluticasone 0.005% ointment 0.005% = 0.005 g 100 g (It's a solid mixed in a semisolid base so the concentration is expressed as w/w fraction)
Infusion Calculations Solution: The bag will last 6.7 hours. Time to Replace IV Bags Calculate Bag Replacement Time
First, calculate how long the bag will last, then add that time to the time the IV bag was started.
Hospital Medication Preparation Labeling Medications Syringes
Flag the label so it does not cover any numbers or lines on the barrel of the syringe Process for flagging the label to a syringe: - Step 1: Attach the edge of the label to the syringe Step 2: Fold the label in half - Step 3: Stick the label to itself
Syringe Plunger
Flat end of the plunger and can be touched when injecting or withdrawing fluid The plunger shaft slides in and out of the barrel to withdraw or inject fluid The plunger piston measures the dosage amount
Percentage Calculations Fraction To Decimal To Percent Conversion
Fractions can always be expressed as a decimal.
Sterile Compounding: Needle Sizes Needle Gauge
Gauge measures the thickness of the needle and is noted with G The larger the gauge, the thinner the needle Common needle gauges are 12 G, 16 G, 18 G, 22 G, 25 G, and 30 G Use 18 G to 22 G needles during sterile compounding
Sterile Compounding: Needle Sizes Needle Length
Generally measured in inches and is noted with" • Common needle lengths are %", %", 1", 1.5", 2" and 3" Use 1" to 1.5" needles during sterile compounding
Non-Sterile Compounding Equipment Volumetric Devices
Glass conical and cylindrical graduates Used to measure exact volumes of liquids or Sizes range from mL to 1,000 mL amber General rule is to use graduate size closest to the amount being measured Use 20% rule for maximum accuracy when choosing graduate Reading the volume - Place graduate on a flat surface Read at eye level Read the bottom of the meniscus
Non-Sterile Compounding Mortars and Pestles
Glass mortar and pestle - Used for liquid preparations, oily chemicals, or chemicals that stain - Preferred when reducing particle size Less porous surface Less risk of cross contamination Porcelain and ceramic mortar and pestle Used to blend powders in or pulverizing soft materials and crystals Electric mortar and pestle Used for mixing, but not to reduce particle size
P Non-Sterile Compounding Weighing paper
Glassine paper is a type of weigh paper Used to weigh ointments, creams, or powders Makes it easier to scrape ingredients off the paper Protects the ingredients from metal pans
Drug Concentrations Practice Problems Pharmacy Example
How many MILLIGRAMS of the active ingredient, chlorhexidine gluconate, are in each 15 mL dose? Step 1: Convert the drug concentration percentage to a fraction 0.12% = 0.12g (It's a solid dissolved in liguid, so the concentration is expressed as w/v fraction) Step 2: Set up ratio-proportion equation, then solve 0.12 g = x g 100 mL 15 mL (0.12 g)(15 mL) = x g 100 mL x = 0.018 g Step 3: Convert g to mg (0.018 g)(1.000 mg) = 18 mg 1 g Solution: There are 18 mg of chlorhexidine gluconate in each 15 mL dose of Peridex 0.12% oral rinse.
Dilution Calculations Points Recap Definitions
How much drug is contained in the product
Infusion Calculations Flow Rates
How much volume of a medication or fluid a patient will receive over a period of time. Flow rates are expressed in volume units per a specific time unit, usually as milliliters per hour (mL/hr).
parenteral Dosage Forms Abbreviations Parenteral
IV = Intravenous; can be confused for IM or ID IM = Intramuscular; can be confused for IV or ID ID = Intrademmal; can be confused for IV or IM SubQ, SC, SQ = subcutaneous; can be confused for SL or the Q for AUAM.
Communication During Medication Reconciliation Non-Verbal Communication
If hard-of-hearing, use handwriting and pictograms to communicate
Percentage Calculations Percents Definition
In Latin, percent means "per 100." A percent is the number of parts of something per 100 parts. Examples of percentages in the pharmacy: hydrocortisone 1% cream or 0.9% sodium chloride solution.
Personal Protective Equipment (PPE) Personal Protective Equipment (PPE) Donning Order
In the ante room 1. Shoe coverings 2. Hair cover 3. Beard cover (if applicable) 4. Face mask 5. Eye shield (if applicable) 6. Non-shedding gown In the buffer room 7. Sterile gloves
Personal Protective Equipment Doffing Order of PPE In
In the ante room 1. Sterile gloves 2. Non-shedding gown 3. Eye shield (if worn) 4. Face mask 5. Beard cover (if worn) 6. Hair cover 7. Shoe coverings
Alligation Calculations Calculate Amount (g, mL) of Higher Strength Product Needed
Total # parts = Amount we need
Alligation Calculations Calculate Amount (g, mL) of Lower Strength Product Needed
Total # parts = Amount we need Y
Equipment Counterbalance
Type of two-pan balance
Crash Boxes Technician's Role Charge Crash Box Medications
Use the hospital charge form to report which medications were used in a code event Compare the par level of each med to the current amounts of meds in the used crash box to determine: Which med to charge the patient What amount to charge the patient Deliver form to medical billing (if required by hospital policy)
Crash Boxes Technician's Role Refill the Crash Box
Use the hospital refill form to: Determine which meds were used in the code Ensure the right strengths and dosage forms are stocked in the crash box Apply appropriate auxiliary labels to refilled medications - "Not for Injection" on vials of sterile water "Warning: Paralyzing Agent" on vials of succinylcholine and rocuronium "Must Be Diluted" on vials of potassium Keep refill form with the restocked crash cart to be checked by the pharmacist
Non-Sterile Compounding Equipment Spatulas
Used for mixing ointments, creams, or transferring chemicals Comes in variety of sizes Comes in stainless steel, hard rubber, and plastic
Specialized Needles Filter Needle
Used for withdrawing solution from ampules Prevents broken glass from contaminating the medication Never used to inject medication into a patient
Sterile Compounding: Supplies and Equipment Y-Site Compatibility Purpose
Used so the nurse doesn't have to start another IV line in the patient's veins IVPB medications connect at a "y-site"
Sterile Compounding: Syringes and Needles Specialized Needles Vented Needle
Used to add diluent to powdered medication in a vial Prevents foaming of powdered medications when diluent is added to it
Infusion Calculations Infusion Time Formula
Used to calculate how long an IV bag will last the patient Volume of fluid (mL) x flow rate (hr)
Non-Sterile Compounding Equipment Syringes
Used to measure an exact liquid volume
Needles
Used to puncture a vial or IV bag
Sterile Key Points Recap Compounding: Non-Needle Syringe Attachments Luer-to-Luer Connectors
Used to transfer the contents of one syringe to another Used to split the volume of one syringe into two syringes
Non-Sterile Compounding Key Points Recap Equipment
Used to weigh large amounts of ingredients and bulk materials • Weighs up to 5,000 g (5 kg) • Sensitivity requirement is +/- 100 mg
P Non-Sterile Compounding Equipment Plastic Weighing Boats Used
Used to weigh larger amounts of creams, ointments, or powders Walls of the boat prevent spills
Sterile Compounding: Supplies and Equipment Other Equipment Dispensing Pins
Used to withdraw from the same vial multiple times Prevents coring Luer-lock syringe attaches to the pin Must be used in the flow hood
Sterile Compounding: Points Recap Syringes Description
Used to withdraw or inject solutions, such as medications and sterile water Made of special plastic and rubber that don't react with most solutions
Medication Order Delivery Fax
Uses fax machine to send medication orders throughout the hospital Faxes are sometimes hard to interpret and can cause errors This method is being phased out for more reliable alternatives for delivery
Medication Order Delivery Oral (Verbal)
Uses telephone to call medication orders into the pharmacy by medical staff Mostly used for STAT orders, as well as clarification of medication orders Some states allow technicians to receive oral medication orders over the phone
Hospital Medication Preparation Auxillary Labels Refrigerate/Freeze Auxiliary Labels
Usually blue or white with blue print Usually contains the phrase "Refrigerate: Do not Freeze" or "Keep in Freezer" - Examples of meds that require refrigeration include epoetin, filgrastim, and amphotericin B Examples of meds that require freezing include varicella vaccine and snake/spider antivenom Informs the pharmacy and medical staff to proper storage since storing a med at the wrong temperature can destroy it
Auxiliary Labels Medication Strength Auxiliary Labels
Usually contains the phrase "Check strength" Informs the medical staff that the drug strength dispensed is different than the strengin prescribed
Hospital Medication Preparation Auxillary Labels Do Not Shake Auxiliary Labels
Usually contains the phrase "Do Not Shake" Informs the medical staff to NOT shake the medication when handling it since shaking can destroy the medication Examples of meds that should NOT be shaken include epoetin drugs
Hospital Medication Preparation Auxillary Labels Shake Well Auxiliary labels
Usually contains the phrase "Shake Well" Informs the medical staff to shake the medication before administration since the drug may settle to the bottom of the vial or bottle • Examples of meds that must be shaken before administration include most suspensions
Hospital Medication Preparation Auxillary Labels Chemotherapy Auxiliary Labels
Usually yellow in color Usually contains the phrase, "CAUTION: CANCER CHEMOTHERAPY. HANDLE AND DISPOSE OF PROPERLY Informs the pharmacy and medical staff that they are handling chemo meds and must take appropriate precautions
Infusion Calculations Drip Rate Equation (gtt/min) •
Volume (mlL) x Drop Factor (gtt/mL) Time (min)
Dilution Calculations Formulas Example
You have 100 mL of a 50% dextrose solution, but you need dextrose 5% solution. How many mL of 5% solution can be made from the 50% solution? How much diluent (water) do you need to add? Step 1: Set up the equation with the known values: (q1)(c1) = (q2)(c2) (100 mL)(50%) = (x mL)(5%) Step 2: Divide both sides by 10% to get "x" by itself (100 mL)(50%) = (x mL)(5%) (5%) (5%)
Compounding Calculations Practice Problems How to Decrease the Compounding Formula Example
You need to prepare 30 g of cream using this formula. How much of each ingredient do you need? Coal tar 3 g Salicylic acid 2 g Triamcinolone 1% cream 15 g Eucerin cream 100 g Yields 120 g
Infusion Calculations Drip Rate Example
You receive the following medication order. Heparin 20,000 units/100 mL over 45 minutes. How many drops are in each minute if you have a 15-drop set? Step 1: Set up the formula. 100 mL x 15 gtt 45 min 1 mL Step 2: Multiply the numerators. 100 x 15 = 1,500 Step 3: Multiply the denominators. 45 x 1 = 45 Step 4: Divide. 1.500 = 33.3 drops/min 45 Solution: The patient will receive 33.3 gtt/min.
Infusion Calculations mL/hr Example
You receive the following order: 1.000 ml, of 0.9% sodium chloride, infuse IV over 24 hours. What is the flow rate in mL/hr? Step 1: Set up volume over time. 1.000 mL 24 hr Step 2: Divide the numerator by the denominator. 1.000 mL = 41.7 mL 24 hr hr Solution: The patient will receive 41.7 ml per hour.
Infusion Calculations Infusion Time Example
You receive the following order: normal saline 1,000 mL running at 150 mL/hr. How long will the bag last the patient? Step 1: Set up the formula. 1,000 mL x 1 hr 150 mL Step 2: Multiply the numerators. 1,000 x 1 = 1,000 Step 3: Multiply the denominators (1 can be used as the place holder for 1000 mL). 1 x 150 = 150 Step 4: Divide. 1,000 = 6.7 hr 150 Solution: The bag will last 6.7 hours. (Some hospitals may round this number down)
Alligations Practice Problem Practice Problem Example
You receive the following prescription Zinc oxide 3% cream Sig: apply prn Disp: 454 g
Percentage Calculations Fraction To Decimal To Percent Example
You take an exam that contains 95 questions. You get 82 questions correct. What percentage of the questions did you get right? Step 1: Convert the fraction 82/95 to a decimal: 82 divided by 95 = 0.86 Step 2: Convert 0.86 to fraction. 0.86 1 Multiply both the numerator and denominator by 100: (0.86) (100) = (0.86)(100) = 86 1 100 100 100 That gives a fraction with the denominator of "100." Step 3: Convert the fraction to a percent. Drop the denominator and add the percent sign. Answer: 86%. Firot Conuert Frahon
Sterile Compounding: Recap Supplies and Equipment Other Equipment Amber Bags
ethod Covers an IV bag or syringe to protect light-sensitive medications Examples include aminophyline, dopamine, and furosemide
Dilution Calculations Dilution
he process of adding inactive ingredients to make a mixture of lower strength, or concentration, than the product you started with
Non-Sterile Compounding After Beyond-Use Dating Definition
ital The date after which a compounded preparation is not to be used Is determined from the date the preparation is compounded and the type of formulation A beyond-use date must be included on the labeling of ALL compounded drug products arge An extemporaneous compounded product must have a beyond-use date of 6 months or less
Medication Order Types Standing Order
medication order placed for a patient in advance of a condition Before surgery or if a condition is met, such as blood levels or temperature are too high or too low
Infusion Calculations IV Bag Replacement Time Example
patient receives a 1 liter bag of IV fluids started on 8 AM on Saturday. It's infusing at 40 mL/hr. What time will the bag need to be replaced? Step 1: Use the equation, volume x flow rate. 1LX1 hr 40 mL. Step 2: Convert 1L to mL. 1Lx 1.000 mL x 1 hr 1L 40 mL Step 3: Multiply the numerators. 1 x 1,000 x 1 = 1,000 Step 4: Multiply the denominators. 1 x 40 = 40 Step 5: Divide. 1.000 = 25 hours 40 The bag will last 25 hours. Step 6: Add the hours to the time the bag started. 8 AM + 25 hours = hours, or (military time) Solution: The bag will need to be replaced at 9 AM (0900) on Sunday Some hospitals have policies to change bags every 24 hours.
Drug Concentrations
product's "concentration" tells you how much drug is contained in the product
Preparation of Sterile Compounds Recap Compounding Process Assemble Needle/Syringe
wall Securely attach needle to syringe Leakage can occur if needle isn't attached correctly to syringe
P Non-Sterile Compounding Pharmaceutical Brass Weight Set
• Used with two-pan balances in measuring and calibrating balances • Made of brass Handle with forceps or cloth, not fingers Use forceps for smaller weights - Use a cloth or other type of barrier for larger weights
Hospital Medication Preparation Auxillary Labels Allergy Auxiliary Labels
• Usually contains the phrase "Check allergies" Informs the medical staff to medications that contain ingredients that can pose life-threatening consequences when administered to a patient who is allergic Examples of common allergens include peanut, soy, penicillin, and sulfa
Chemotherapy Compounding: Overview Administration
• Usually given slowly to the patient to prevent infusion reactions Pain and damage to veins Done in rounds to prevent toxic buildup of chemo in the system
KP Chemotherapy Compounding: Chemotherapy Orders Overview
Contains specific chemo drugs and doses, pre-medications, and lab orders Patients with cancer usually need specialized chemo doses Too high of a dose can be more toxic Too low of a dose can undertreat the cancer
Percentage Calculations Percent To Fraction Example
Convert 42% to a fraction. Step 1: Make the number in the percent your numerator Step 2: Drop the percent sign Step 3: Make the denominator 100 42/100 Answer: 42% = 42/100
Chemotherapy Preparation Chemotherapy Compounding Procedures Overview
1. Clean vial, one swipe of the alcohol pad towards the side wall of the hood 2. Pierce vial's rubber stopper, using the proper CSTD 3. Withdraw fluid from vial, using the proper CSTD 4. Carefully remove bubbles from the syringe
Chemotherapy Preparation Chemotherapy Spills Chemotherapy Spill Cleanup 1. Procedure
1. Clear area of staff and patients 2 Place warning signs around spill 3. Check SDS for proper procedure for cleaning spill 4. Grab spill kit and put on included chemo PPE 5. Places towels on liquid spills or use dustpan to sweep up powdereddrug 6. Throw towels in chemotherapy bag or powder in puncture-resistantcontainer 7. Use appropriate cleaner to clean the area 8. Place all PPE and other items in biohazard bag 9. Place biohazard bag in chemo sharps container 10. Fill out incident report
Aseptic Handwashing Aseptic Handwashing Procedure
1. Remove all jewelry and nail polish; make sure nails are trimmed to %" length 2. Don shoe covers, hair cover, and face mask 3. Expose arms and elbows 4. Turn on the water and wait until it gets warm, then wet arms and hands Don't touch faucets until handwashing procedure is complete 5. Open scrub brush packet and take out sponge brush and nail pick Don't set the brush and nail pick down 6. Use nail pick to clean underneath each fingernail on both hands 7. Squeeze sponge brush until lather forms 8. Use brush side of sponge brush to clean underneath each fingernail Some facilities do not use the brush side, due to potential contamination of sterile product with skin cells 9. Use the sponge side of the sponge brush, and repeat on each hand, to clean: All sides of thumb and fingers In between the fingers (webbing) Palm of hand Back of hand 10. Use the sponge side of sponge brush, clean forearm in a circular motion starting at the wrist 11. While keeping fingers and arms pointed upwards, rinse hands and forearms 12. Keeping fingers and arms pointed upwards, use lint-free towels or electric dryer, to dry hands and arms
Preparation of Sterile Compounds Compounding Process Injecting Meds Into IV Bags
Correct injection port usually has a rubber stopper or sometimes states "ADD" above it Insert needle horizontally and inject medication into the correct port on IV bag If resistance is felt, take out needle and reinsert until insertion is smooth
Sterile Compounding: Supplies and Equipment Other Equipment intravenous Aomiture VA) Seal Aiso
Aiso known as a fol port cover Covers the port of an V bag ater the medicine has been injected Protects the pot from contamination Aiso used to cover the rubber stopper of an MDV
Alligations Alligation Table Setup
A = percent concentration of the higher strength product B = percent concentration of the lower strength product C = percent concentration of the intermediate strength product Z = parts of higher strength Y = parts of lower strength Calculate Z and Y - C = Y parts
Medication Orders Medication Order Types Stat Order
A medication order for immediate administration Includes medications that are needed ASAP due to a medical emergency Usually need to be completed and sent to nursing staff in under 15 minutes
Medication Order Types Discharge Order
A medication order for the patient when they leave the hospital Includes medications the patient should start when they get home Includes additional instructions for non-pharmacologic treatments
Medication Order Types Daily Order
A medication order placed after the patient is admitted to hospital Includes medications the prescriber wants the patient to take on daily basis while in hospital
Medication Order Types Admitting Order
A medication order placed when the patient is first admitted to the hospital Usually comes from the emergency department, but can also come from different areas of the hospital or different hospitals Includes new medications and any home medications the prescriber wants the patient to continue while in the hospital
Time to Replace IV Bags IV Bag Replacement Time Example
A patient receives 1 liter of Lactated Ringers with 20 mEq of potassium chloride. The infusion rate is 250 mL/hr. How long will one bag last? Step 1: Use the equation, volume x flow rate. 1 Lx1 hr 250 mL
Non-Sterile Compounding Blending Techniques Geometric Dilution
A series of dilution steps to mix two or more ingredients - Add the smallest quantity ingredient first - Add the same amount of second ingredient as the smallest-quantity ingredient; mix to combine - Add the same amount of the next ingredient as is in the mixture Keep increasing the amount of ingredient added to equal the amount of mixture
Compounding Key Terms Compounding Formula
A whtten document that lists the ingredients and instructions needed to prepare a compounded product
IV Bags Common Base Solutions
Abbreviation Name NS Normal Saline or 0.9 % Sodium Chloride % NS % Normal Saline or 0.45% Sodium Chloride D5W Dextrose 5% in Water D10W Dextrose 10% in Water D5NS Dextrose 5% in Normal Saline LR Lactated Ringer's Solution D5LR Dextrose 5% in Lactated Ringer's Solution
Alligation Calculations Calculate Total # of Parts
Add Z and Y to get number of total parts for the final product
Chemotherapy Compounding: Chemotherapy Orders Base Solutions
Administering D5W and normal saline can prevent dehydration during chemotherapy administration and prevent the drug from damaging the kidneys • Electrolytes may be added to prevent depletion of certain electrolytes
Medication Reconciliation (Med Rec) Overview When is a Medication Reconciliation Performed?
Admission to hospital, transition of care, and discharge from hospital Transition of care is when the patient is moved from one department to another in a hospital
The Laminar Flow Hood Two Horizontal Flow Hood
Air travels through a prefilter and HEPA filter to sterilize Sterile air blows horizontally towards the compounder Used to compound non-hazardous medications, such as antibiotics, electrolytes, and cardiovascular medications Shadowing can occur if objects are placed in front of each other
The Laminar Flow Hood Vertical Flow Hoods Parallei From Face
Air travels through a prefilter and HEPA filter to sterilize Sterile air blows vertically on the workbench Any contaminated air passes through a second HEPA filter in an exhaust vent Used to compound hazardous medications, such as chemotherapy Shadowing can occur if objects are placed on top of each other
Medications in the Hospital Setting Unit-Dose Medications
Contain single doses of tablets, capsules, suppositories, or oral liquids Sealed to prevent contamination of the medication Normally stocked in automated dispensing cabinets or manual cassettes for nurse's use Each unit-dose package mustcontain (can vary on hospital policies and state laws): - The drug's name, strength, dosage form, lot number, manufacturer, NDC number, and expiration date - A bar code
Preparation of Sterile Compounds Recap Compounding Process Removing Air Bubbles Bubbles
Bubbles can cause harm if injected into the patient and take the place of where medication should be Pull the syringe slightly past the volume needed and tap the syringe where air bubbles are located until they rise to the syringe hub Push plunger to correct volume
Sterile Compounding: Supplies and Equipment Vials Description
Contains medication or diluent to be drawn up with a needle and syringe Made of glass or plastic, with a rubber stopper on top To prevent contamination, don't touch the rubber stopper with your hands
Sterile Compounding: Supplies and Equipment Single-Dose Vial (SDV)
Contains no preservatives Must be discarded after first use
Alligation Calculations Calculate Z and Y
Calculate Z and Y by subtracting diagonally A - C = Y parts of lower strength • B - C = Z parts of higher strength
Sterile Compounding: Recap Syringes Syringe Tip
Can be Luer-lock or slip-tip Luer-lock can be used with all medications DON'T use slip-tip with chemotherapy medications Not safe to touch
Preparation of Sterile Compounds Sterile Compounding Precautions IV Incompatibilities
Certain drugs, when combined, can cause precipitation or make the drug inactive If an incompatibility happens, throw away the compound and inform your supervisor
Chemotherapy Compounding: Overview Key Chemotherapy Storage and Handling Product Selection
Check product label to ensure right chemotherapy product is selected Be on the lookout for "TALL man" lettering with chemotherapy meds when selecting products
Medications in the Hospital Setting Safety Considerations
Chemotherapy can be absorbed into the body through skin or lungs and cause damage Wear special chemotherapy personal protective equipment (PPE) when handling chemo Teratogens such as dutasteride, finasteride, bosentan, and ambrisentan can cause birth defects to a developing fetus - Pregnantwomen, or women planning to become pregnant, should: Avoid contact with broken tablets and liquid suspensions of these meds Wear gloves and face mask when handling intact tablets or capsules of these meds Medications that you are allergic to should be avoided or handled with care Use nitrile gloves if you are allergic to latex
Chemotherapy Preparation Chemotherapy Flow Hoods Compounding Aseptic Containment Isolator (CACI)
Chemotherapy vertical flow hood that is completely enclosed Uses a pair of attached gloves for chemotherapy manipulation
Chemotherapy Preparation Compounding Aseptic Chemotherapy Containment Isolator (CACI)
Chemotherapy vertical flow hood that is completely enclosed Uses a pair of attached gloves for chemotherapy manipulation
Chemotherapy Preparation Chemotherapy Flow Hoods Biological Safety Cabinet (BSC)
Chemotherapy vertical flow hood with an acrylic barrier to help protect the compounder's face and upper body from chemo exposure Not completely closed off, so the compounder can still be exposed to chemotherapy
KP Chemotherapy Preparation Biological Safety Cabinet (BSC)
Chemotherapy vertical flow hood with an acrylic barrier to help protect the compounder's face and upper body from chemo exposure Not completely closed off, so the compounder can still be exposed to chemotherapy
Non-Sterile Compounding Blending Techniques Blending
Combining two substances together
Syringe Sizes Common Syringe Sizes Common
Common syringe sizes are 0.5 mL, 1 mL, 3 mL, 5 mL, 10 mL, 20 mL, 30 mL, 60 mL The barrel has demarcations that measure increments in mL or cc (1 mL = 1 cc)
Medications in the Hospital Setting Medication Dosage Forms Commonly
Commonly dispensed dosage forms in hospitals include: Tablets Capsules Solutions Suspensions Creams IIII Ointments - Lotions Patches Eyelear drops IIIII Inhalers Suppositories Nebulizer solutions IV push (IVP) IV piggyback (IVPB) Large volume parenteral (LVP)
Compounding Calculations Compounding Definition
Compounding is the process of mixing raw ingredients or prepared ingredients together to prepare a drug product for a patient
Automated Dispensing Cabinets (ADCS) Definition
Computerized devices used to store and dispense medications
Crash Boxes Crash Box Contents
Contain a specific type and amount of vital medications to be used by medical staff during code events Most meds are for cardiac (heart) or pulmonary (lung) resuscitation emergencies
Sterile Compounding: Supplies and Equipment Recap Vials Multi-Dose Vial (MDV)
Contains preservatives Can be punctured multiple times Has a beyond-use date (BUD) of 28 days from the first puncture, if specific BUD not stated on the label or package insert
Automation: Institutional Bar Codes Scanning Errors
Could be the result of physical problems E.g., bar code won't scan due to reflective surfaces
Key Non-Needle Syringe Attachments Syringe Cap
Covers the end of the syringe Prevents contamination of the syringe tip during transportation
Needles Сар
Covers the needle Protects from accidental puncture • Only capped needles are safe to handle
Lyophilized Powders
Drug comes as a freeze-dried powder in a glass vial to extend shelf-life of med
Percentage Calculations Key Points Recap Percents sodium Drug Concentrations Drug
Drug concentrations are often written as a percentage of the base in which they re dissolved. For example, the solution dextrose 5%. There are 5 parts of dextrose in 100 parts of solution 5 parts dextrose 100 parts solution
Non-Sterile Compounding Technician Duties
Duties will vary depending on state laws and pharmacy policies Some duties include Weighing, measuring, and mixing ingredients Ordering supplies Maintaining a clean work environment
Crash Boxes Technician's Role Preparation of the Crash Box for Pharmacist Verification
Ensure the crash box is completely stocked Double-check that the refill form is filled out Initial and date the refill form
Non-Sterile Compounding Recordkeeping Formulation Record
Essentially a recipe book Includes everything needed to prepare a formulation Name, strength, and dosage form of the compound Ingredients and quantities Required equipment Mixing instructions Assigned beyond-use date Appropriate container for dispensing Storage requirements Quality control procedures Source of recipe
Non-Sterile Compounding Digital Electronic Scale
Has one pan • More accurate than two-pan balances Needs to be calibrated Needs to be leveled Use the lid to prevent drafts from altering the reading Press the tare button to turn it on and to reset the scale after placing weigh paper/boat
Non-Sterile Compounding After Beyond-Use Dating Have All Other Formulations Have
Have a 30-day maximum beyond-use date The date is not later than the intended duration of therapy, or 30 days, whichever is earlier
Nonaqueous Liquid and Solid Formulations
Have a 6-month maximum beyond-use date reat it If the source of the ingredient(s) is a manufactured drug product, the beyond-use date is not later than 25% of the time remaining until the original product's expiration date, or 6 months, whichever is earlier
Medication Reconciliation (Med Rec) Overview What is the Purpose of a Medication Reconciliation?
Helps identify and prevent potential medication errors
Parenteral Dosage Forms Intravenous (IV) Medications Injected
Injected into a vein Large-volume preparations (LVP) contain > 250 mL of liquid Usually dispensed in IV bags and given as infusion Examples include fluids for dehydration and parenteral nutrition (PN) Small-volume preparations (SVP) contain s 250 mL of liquid - Usually dispensed in minibags and given over a short period of time Usually piggybacked to the primary IV line (IV piggyback/IVPB) IV push - medication is in a vial or syringe and will be injected directly into the primary IV line Can be solutions (solid ingredients completely dissolved) or emulsions (mixture of oil and water), NOT suspensions Need to have similar chemical properties as blood Isotonic solutions have the same number of dissolved particles as blood Examples include 0.9% sodium chloride, D5W, Lactated Ringer's - Hypertonic solutions have a greater number of dissolved particles than blood Cause cells to shrivel Must be administered into large vein Examples include 3% sodium chloride and D1Ow Hypotonic solutions have a fewer number of dissolved particles than blood Cause cells to swell Can lead to electrolyte imbalances Examples include 2 strength (0.45%) normal saline
Parenteral Dosage Forms Intramuscular Medications
Injected into muscle, usually the buttocks or deltoid Can be solutions or suspensions Can be used in outpatient setting Duration of action longer than IV - Aqueous meds may work within minutes Oil-based meds may take longer to work or linger in muscle Absorption may be unpredictable and may not give steady levels .. Examples - Most flu vaccines (Fluzone, Fluarix, Flublok, etc) Vitamin B12 (cyanocobalamin) Testosterone (Depo-Testosterone, Delatestryl, etc) - oil-based; one injection may last up to 4 weeks Medroxyprogesterone (Depo-Provera, etc) - oil-based; one injection may last up to 90 days Olanzapine injection (Zyprexa Relprevv) - one injection may last up to 4 weeks
Communication During Medication Reconciliation Introduction
Introduce role as a medication reconciliation technician Let the patient know the reason why a medication reconciliation is being performed If the patient doesn't speak English, find an interpreter in the patient's native language
Preparation of Sterile Compounds Points Recap Compounding Process Withdrawing Fluid From The Vial
Invert the vial and syringe and inject air into the vial Use the milking technique to inject small amounts of air at a time Continue with milking technique until the desired volume is achieved
Ampules Safety Concerns
Keep fingers away from ampule neck when breaking Some pharmacies may use an ampule breaker to prevent injury from broken glass Throw away ampule glass in a sharps container
Compounding Recap Non-Sterile Compounding Maintaining Reasons for Compounding
Lack of availability of a specific dose or dosage form Commercially available products don't meet the patient's needs
Practice Problems How to Increase the Compounding Formula Example
Let's say you need to prepare 60 mL of ear pain drops using this compounding formula. How much of each ingredient will you need? Antipyrine 1.8 g Benzocaine 0.5 g Glycerin QSAD 30 mL To figure out how much to increase each ingredient, you'll divide the total number of mL you want by the total number of mL the formula yields. # mL you want = 60 mL = 2 = 2 # mL formula yields = 30 mL 1 You'll multiply each ingredient quantity by 2. Antipyrine 1.8 g x 2 = 3.6 g Benzocaine 0.5 gx 2 = 1g Glycerin QSAD 30 mL x 2 = 60 mL
Cleaning the Laminar Flow Hood Cleaning Supplies
Lint-free towels or gauze Sterile water 70% isopropyl alcohol (IPA)
The Laminar Flow Hood Overview
Located in the buffer room Sterile compounding is performed on the laminar airflow workbench (LAFW) Contains a High-Efficiency Particulate Air (HEPA) filter, hang bar, workbench, and side walls Must have an air quality of ISO Class 5 Two different types: horizontal flow hood and vertical flow hood
Medication Reconciliation List Recording Medication Information
Medication reconciliation is usually done electronically, but can also exist on paper form When completing a med list, be sure to include the following - Drug name, strength, dosage form, route of administration, indication, and directions Note if the drug is a sustained or extended release product Write out directions entirely and don't use abbreviations or sig codes Include when a patient started and stopped a medication, if applicable Record the last day and time the patient took their medication If the patient can't speak or remember the information, a family member or caregiver can be asked Try to get as much information as possible during the med rec interview Outside resources, like the patient's prescriber or community pharmacy, can be contacted to fill any gaps in the med rec list
Medication Reconciliation Types Of Medication Errors Drug-Drug Interactions Most
Most common medication error Occurs when the patient takes multiple drugs that have dangerous interactions with each other
Medications in the Hospital Setting Overview
Most hospitals dispense medications to patients for 1 dose or 1 day Medications are directly administered to the patient by hospital staff
Cleaning the Laminar Flow Hood Procedure
Must be fully garbed in PPE before cleaning Flow hood must be on for at least 30 minutes before cleaning • Using sterile water and lint-free towels or gauze, clean in this order: 1. Hang bar and hooks 2. Ceiling, starting with either back corner, using side-to-side overlapping motions 3. Side wall, starting in the upper back corner, using up-and-down overlapping motions 4. Other side wall, starting in the upper back corner, using up-and-down overlapping motions 5. Workbench, starting with either back corner, using side-to-side overlapping motions Inspect the hood after cleaning for any dirty areas Repeat above steps with new lint-free towels or gauze and 70% IPA Fill out hood cleaning log after cleaning flow hood
Chemotherapy Preparation Key Chemotherapy Equipment & Supplies Closed-System Transfer Device (CSTD)
Needle-less system to transfer chemotherapy medication from a vial to asyringe Such systems are now required by USP <800> Reduces accidental needle sticks Dispose of CSTD in chemotherapy sharps container when done
Chemotherapy Preparation Chemotherapy Spills Chemotherapy Spill Kit Occupational available
Occupational Safety and Health Administration (OSHA) requires that a chemotherapy spill kit be available when chemo is compounded or administered Spill kit components can vary, but most contain: Safety glasses Chemo gown Chemo gloves Face mask Biohazard bag Absorbent towels or mat Dustpan and broom Clean-up instructions Puncture-resistant container Sharps container
Medication Reconciliation Types Of Medication Errors
Occurs when patient has a disease or condition, but is not currently taking any meds to treat it
Non-Sterile Compounding Common Compounded Dosage Forms
Oral solutions Oral suspensions Topicals Creams Ointments - Gels
Syringe Guard
Part of the syringe that provides leverage when injecting or withdrawing fluid Can be touched safely when injecting or withdrawing fluid
Needles Hub
Part that attaches to the syringe tip Either twists on (Luer-lock) or slips on (slip-tip) • Touching the needle hub can cause contamination
Medication Orders Medication Order Information Required Information
Patient name Patient height and weight DOB Allergies Drug name, strength, dosage, route of administration, and frequency Prescriber signature and date Diagnoses Room number Time order is to be given May be ven in military time May include vital signs and lab orders
Medication Reconciliation List Information to Document Patient's from Patient
Patient's name and birth date Ensures you are gathering information from the right patient Medications Include prescription and OTCS drugs, herbals, dietary supplements, and drug samples Patient's allergies Include drugs, foods, dyes, and latex Include the description of the allergy or allergies Community pharmacy or pharmacies used May need to contact pharmacy for additional medication history Immunizations - If the patient needs a specific immunization, it can be given during their hospital stay
Percentage Calculations Percent To Fraction Conversion
Percentages can always be written as a fraction with a denominator of 100. To change a percent to a fraction, make the number in the percent your numerator. Drop the percent sign. Then make the denominator "100." The rules are the same if the percentage has a decimal point.
Medication Reconciliation (Med Rec) Overview Who Performs a Medication Reconciliation?
Pharmacy technicians generally only perform a med rec at admission to the hospital Nurses, pharmacists, and prescribers perform a med rec during transition of care or discharge
Chemotherapy Preparation Chemotherapy Compounding Procedures IV Tube Preparation
Pharmacy technicians must prep the IV tube BEFORE placing drug into the IVbag IV tube preparation procedure 1. Gather IV bag, IV tubing. gauze, and needle 2. Insert tubing spike into IV bag 3. Attach needle on the other end of the IV tubing 4. Pinch drip container 5. Roll tubing clamp upward to allow fluid to flow from IV bag, down the tubing 6. Stop flow when fluid starts to drip from the needle end of the IV tubing 7. Check tubing for any air bubbles
parenteral Dosage Forms Syringes
Pick syringe size closest to injected volume Do not use tuberculin syringes for IM injections (not long enough) • Only use insulin syringes for insulin orders They're marked in units 100 units = 1 ml
Preparation of Sterile Compounds Recap Compounding Process Labeling IV Bags
Place med order label either: On the front of the bag, beneath the bag's list of contents - On the back, or clear side, of the bag • If unsure where to place the label, consult your pharmacy's protocol
Hospital Medication Preparation Labeling Medications Tablets or Capsules Place medication
Place medication inside a clear zip-top bag and seal Place the label on the opposite side of the bag that has the tablet or capsule drug informa
Chemotherapy Preparation Chemotherapy Compounding Procedures Labeling of IV Bag
Place warning stickers on compounded chemotherapy IV bag or syringe
Preparation of Sterile Compounds Points Recap Compounding Process Disposal and Recapping
Place wrappers and caps into the regular trash Place anything sharp into the sharps container - Includes needles and broken ampules or vials • Use the one-handed scoop method to recap a needle
Non-Sterile Compounding Comminution Techniques Comminution
Reducing a substance to fine particles
Medication Orders Communication in the Hospital Verbal Communication Refer
Refer to the caller by correct title Laut Physicians (MDs, DOs) are referred to as "Doctor" Then Name Other prescribers, nurses, and pharmacists are usually referred to by their first name Identify yourself by using your name and location Speak clearly Ask the caller to repeat themselves if not heard correctly the first time Use the tell-back method
Automated Dispensing Cabinets (ADCS) Technician's Role
Run refill reports and restock medications as needed Troubleshoot bar codes that won't scan or are mapped incorrectly to products
Chemotherapy Preparation Chemotherapy Equipment & Supplies Chemotherapy Personal Same Protective Equipment (PPE)
Same sterile garb as with hazardous non-sterile medications, in addition to: Safety goggles Chemotherapy gown, in place of the sterile gown used in non-chemo compounding Chemotherapy gloves, to be worn over sterile gloves Face shield (facility-specific) Dispose of gloves and sterile gown used in chemotherapy sharps container
Chemotherapy Compounding: Chemotherapy Storage and Handling Storage
Separate from non-chemo medications to prevent contamination of other medications Keep in colored bins (yellow or red) to signify chemo meds Keep look-alike/sound-alike (LASA) chemo meds away from each other or use shelf tags to warn staff
Parenteral Dosage Forms Dispensing Tips Types of Vials
Single-dose vials/ampules are for one-time use because they do NOT contain preservatives Multi-dose vials can be used more than once because they contain preservatives Prefilled syringes have medication already measured in a syringe with the needle attached, reduce dosing and administration errors
Key Sterile Compounding: Supplies and Equipment Y-Site Compatibility Considerations
Some items don't mix well at the y-site Ampicillin and gentamicin cancel each other out and make each ineffective Phenytoin and D5W can form a white precipitate Check with the pharmacist if you are unsure if medications should be mixed
Chemotherapy Equipment & Supplies Description of Use
Specialized chemotherapy equipment to: Minimize drug spillage Protect compounder and sterile product from contamination
Chemotherapy Preparation Chemotherapy Equipment & Supplies Description of Use
Specialized chemotherapy equipment to: Minimize drug spillage Protect compounder and sterile product from contamination
Chemotherapy Preparation Chemotherapy Flow Hoods Description
Specialized flow hoods designed to protect the compounder and environment from exposure to chemotherapy Airflow is vertical (from top to bottom), with a specialized venting system to properly vent aerosolized chemotherapy out of the pharmacy and away from the compounder
KP Aseptic Handwashing Aseptic Handwashing Definition
Specific step-by-step process of sterilizing hands and arms before sterile compounding Aseptic means "without infection" Use of special supplies to sterilize - Antimicrobial betadine surgical scrub packet, with sponge brush and nail pick Perform only in the anteroom over the sink Must be performed again if leaving the clean rooms
Infusion Calculations Time to Replace IV Bags
Step 2: Convert 1L to ml. 1 Lx 1.000 mLx1 hr 250 mL Step 3: Multiply the numerators. 1 x 1,000 x 1 = 1,000 Step 4: Multiply the denominators. 1 x 250 = 250 Step 5: Divide. 1.000 = 4 hours 250 Solution: The bag will last 4 hours.
Key Points Recap Personal Protective Equipment (PPE) Reuse
Sterile gloves, face masks, beard, hair, and shoe covers are single use only, and must be thrown away after use. Non-shedding gown can be reused if nothing was spilled on it. Hang on a hook in ante room, making sure it doesn't touch the ground. Eye shields can be reused if cleaned with 70% isopropyl alcohol.
Chemotherapy Compounding: Chemotherapy Orders Premedications
Taken to prevent side effects of chemotherapy, such as nausea, vomiting, and fever Can include the following: - Steroid such as dexamethasone and prednisone - Antihistamine such as diphenhydramine Benzodiazepine such as lorazepam - 5-HT3 antagonist such as ondansetron Antipyretic such as acetaminophen (APAP)
Dilution Calculations Formulas Dilution Formula
The formula for dilution calculations is: (g1)(c1) = (q2)(c2) g1 is the initial quantity c1 is the initial percentage concentration q2 is the final quantity c2 is the final percentage concentration q2 will always be greater than q1, since you ADD diluent to change the concentration • c2 will always be less than c1, since diluting LOWERS the concentration The formula for finding out diluent added is: q2 - q1
Needles Bevel and Tip
The bevel is the slanted opening at the sharply-pointed tip of the shaft • Touching the bevel can cause a needlestick injury Contact your supervisor immediately if you get a needlestick
KP Infusion Calculations Points Recap Flow Rates mensional mL/min Example
The following order arrives in your pharmacy, penicillin G 3 million units in 50 mL over 15 minutes. What's the flow rate in ml per hour? Step 1: Set up volume over time. 50 mL 15 min Step 2: Add in the conversion factor for min to hours. 50 mL x 60 min 15 min 1 hr Step 3: Multiply the numerators. 50 x 60 = 3,000 Step 4: Multiply the denominators. 15 x 1 = 15 Step 5: Divide. 3,000 mL = 200 mL 15 hr hr Solution: The patient will receive 200 mL per hour.
Infusion Calculations Drip Rates
The number of drops of fluid in the drip container over one minute Abbreviated gtt/min
Non-Sterile Compounding Blending Techniques Spatulation
The process of mixing ingredients with a spatula Also known as folding Gentler than stirring and provides a smooth, uniform mixture
Non-Sterile Compounding Comminution Techniques Pulverization
The process of reducing particle size of a solid by using a solvent Common solvents are camphor, alcohol, iodine, and ether The solvent evaporates and doesn't become part of the final compound
Preparation of Sterile Compounds Alternative Preparations Add-a-Vial and Add-Vantage Systems
The vial is aseptically attached to the base solution bag Sterile mixing is done by the nurse Flow hood or buffer room is not needed • If seal is broken, don't use
Syringe Barrel
Where medication is measured This is the best place to hold the syringe safely Use the widest part of the piston when measuring volume
Chemotherapy Preparation Chemotherapy Sharps Container
• Dispose of any item that has been used in chemotherapy compounding in thiscontainer, including: Gloves Sterile Gown CSTDS Alcohol and gauze pads - Syringes Drug vials Usually yellow in color
Automation: Institutional Bar Codes Description
• Found on stock bottles and unit-dose packages - Encodes 10-digit NDC number May include lot number, expiration date, and/or package size Found on medication order labels - May encode medication order number Scan the bottle or unit-dose label to pull up the prescription record Some pharmacy systems require converting from a 10-digit to an 11-digit NDC number for scanning or billing purposes
Chemotherapy Compounding: Chemotherapy Indications
• Generally used to treat cancer May also treat noncancerous conditions such as rheumatoid arthritis, lupus, and psoriasis
Personal Protective Equipment (PPE) Description of PPE Items
• Hair cover (bouffant cap) Covers all hair and ears Prevents contamination of sterile prep from hair and dandruff Face mask Covers nose and mouth Prevents contamination of sterile prep from saliva and mucus Helps prevent accidental inhalation and ingestion of medication Beard cover Covers facial hair and sideburns, if applicable Prevents contamination of sterile prep from facial hair Eye shield Covers eyes Protects eyes from medication exposure Optional to wear in most cases, but needed for hazardous meds Non-shedding gown Covers arms and body Protects arms and the rest of body from medication exposure Prevents contamination of sterile prep from cloth fibers Sterile gloves Covers hands Protects hands from medication exposure Prevents contamination of sterile prep from hands and fingernails Shoe covers - Covers your shoes Prevents dirt and other contamination from shoes from entering the buffer room
Parenteral Dosage Forms Subcutaneous (SubQ, SC, • SQ) Medications
• Injected into fatty tissue just below the skin or subcutaneous layer, usually the outside of the upper arm, top of thigh, or abdomen Can be aqueous solutions or suspensions Can be used in outpatient setting • Most work within minutes • Examples Insulin (some can also be given IV) - Нераrin Sumatriptan (Imitrex)
parenteral Dosage Forms Tips
• Length of needle depends on patient and type of medication Intramuscular Injection • Most adults: 5/8 to 1.5 inch Infants/kids: 5/8 to 1.25 inch Obese patients: 1.5 inch Subcutaneous Injections Most adults: 5/8 inch or lower Infants/kids: 3/16 to 5/16 inch Obese patients: 5/8 inch • Very thin patients: 3/16 to 5/16 inch Gauge of needle depends on the type of medication: the larger the number, the skinnier the needle (tunnel) Intramuscular Injections Most medications: 23- to 27-gauge • Oily medications: 18- to 23-gauge Subcutaneous Injections Most medications: 23- to 27-gauge
Categories of Products Complex
• Preparations that require special training, equipment, facilities, or procedures Includes transdermal or modified-release preparations
Non-Sterile Compounding Recap Comminution Techniques Trituration
• Process of rubbing, grinding, or pulverizing a substance to create fine particles, usually in a mortar and pestle
Automated Dispensing Cabinets (ADCS) Examples
• Pyxis Omnicell • AcuDose-Rx
Preparation of Sterile Compounds Compounding Process Cleaning Vials
• Remove the cap on a vial before cleaning Use one swipe from a 70% IPA pad across the rubber stopper, toward the flow hood's side
Dilution Calculations Key Points Recap Formulas
• Step 3: Solve for "x" (100 mL)(50%) = 1,000 mL (5%) • Step 4: Solve for diluent added, setting up equation with known values 92 - 91 = diluent added 1,000 ml - 100 mL = 900 mL Solution: You need to add 900 mL of diluent (water) to your 50% dextrose solution.
Preparation of Sterile Compounds Sterile Compounding Precautions Needlesticks
• Stop working and inform your supervisor with accidental needlesticks
Chemotherapy Compounding: Chemotherapy Orders Body Surface Area (BSA)
• Surface area of the patient's body Many chemotherapy medications are dosed by patient's BSA Specific dosing can be found in the package insert BSA units are m? BSA equation: square root of Ht (cm)x Wt (kg) over 3,600 = bsa Conversions to remember for BSA equation: 1 kilogram (kg) = 2.2 pounds (Ib) 2.54 centimeters (cm) = 1 inch (in) 12 inches (in) = 1 foot (ft)
Non-Sterile Compounding Extemporaneous Compounding
• The process of making a specific product for a patient when commercially available products aren't available
Dilution Calculations Concentrate
• The product that contains the drug, or active ingredient
Dilution Calculations Diluent
• The product that's mixed with the drug to lower its concentration or "dilute it
