Pharmacy Technician - Sterile Products

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A Brief Overview

Assist in various pharmacy activities, under the supervision of a licensed pharmacist, and other duties not requiring the review of a pharmacist. The majority of tasks and responsibilities are related to preparing, dispensing, and distributing compounded sterile products.

• Microbial contamination
• Excessive bacterial endotoxins
• Variability in the intended strength of correct ingredients
• Unintended chemical and physical contaminants
• Ingredients of inappropriate quality in compounded sterile preparations (CSPs).

What You Will Do

• Practice
• Responsible for accurately preparing patient-specific and non-patient specific doses by ensuring that the compounded sterile products (CSP) are accurately identified, measured, reconstituted, diluted, mixed, sterilized, packaged, labeled, and stored.
• CSPs are prepared aseptically, accurately, and safely in accordance to USP 797, USP 800 and CHOP Pharmacy Standard Operating Procedures (SOP)
• Only medications and ingredients with correct identity, quality and purity are used in the preparation of CSPs
• Ingredients, medications and CSPs are appropriately stored to preserve the sterility and strength until the manufacturer expiration date or CHOP assigned beyond-use date (BUD)
• Equipment, devices, and fixtures are routinely cleaned, appropriately maintained, and used for accuracy and effectiveness for their intended use as per CHOP SOP
• Ensure floors are free of debris and dust. Floors, sink, and all surfaces are cleaned daily as per CHOP SOP
• Labels products with proper information and appropriately assigns the BUD as per CHOP SOP
• Prior to dispensing, ensures all prepared CSPs are verified by a pharmacist for accurate identity, measure, reconstitution, dilution, mixture sterility, packaging, labeling, and storage at the recommended temperature.
• CSPs are prepared within allotted cycle times to ensure that the turnaround time for all first-doses and non-STAT medication orders does not exceed 1 hour and the turnaround time for all STAT medication orders does not exceed 15 minutes
• Responsible for compliance to all federal, state, and department standards and regulations for sterile product compounding- USP797, USP800, CMS Conditions of Participation, FDA Compounding Guidance and TJC standards
• Completes initial aseptic technique training and passes competency test
• Reviews all CHOP Pharmacy SOPs related to CSP preparation and practices
• Completes electronic competency with score ≥ 90%
• CSP microbial contamination risk levels
• Beyond Use Dating
• Environmental Quality and Control
• ISO Class Air Sources, Buffer Area and Ante Area
• Personnel Cleaning and Garbing (Non-Hazardous and Hazardous)
• Cleaning/Disinfection Procedures (Non-Hazardous and Hazardous)
• Complete three consecutive cycles of Non- Hazardous and Hazardous PPE donning/doffing with zero (0) standard work variances including three gloved fingertip test samples with zero (0 CFU) growth results after a 3 day incubation
• Completion of aseptic media fill practical evaluation with zero (0) standard work variances including test media samples with zero (0) CFU growth results after a 14 day incubation
• Completes annual/semi-annual aseptic technique recertification and passes competency test
• Completes electronic competency with score ≥ 90%
• Completes one cycle of Hazardous and Non- Hazardous PPE donning/doffing with zero (0) standard work variances including one gloved fingertip test samples with zero (0 CFU) growth results after a 3 day incubation
• Completion of aseptic media fill practical evaluation with zero (0) standard work variances including test media samples with zero (0) growth results after a 14 day incubation
• Compliant to all dress code and PPE maintenance and associated CHOP Pharmacy SOPs
• No make-up or head/neck/wrist jewelry can be worn
• Appropriate attire in Sterile Product areas
• Scrub sets
• Short-sleeved, collarless shirts
• Full-length pants
• Skirt or dress – NOTE: Stockings/hose MUST be worn with skirt or dress
• Socks covering above ankle
• Cleaning, disinfection, and sanitization of laminar air flow hood (LAFH), equipment, and room at frequency defined USP 797 and CHOP SOPs
• Cleaning all products and supplies with sporicidal cleaning/disinfecting agent prior to introduction across line of demarcation
• Sanitizing all products and supplies with sterile 70% isopropyl alcohol prior to introduction into LAFH
• Sanitizing gloves with 70% isopropyl alcohol prior to introduction into LAFH for dose preparation
• Maintenance of "first air" to all critical sites during dose preparation
• Maintain all required documentation for clean room operations including but not limited to:
• Daily LAFH and work surface cleaning
• Weekly sporicidal LAFH and work surface cleaning
• Monthly sporicidal zone cleaning and inspection
• Daily air pressure differential monitoring
• Weekly eye wash hose functionality
• Execute Patient Specific Daily Batch SVP Production as per CHOP Pharmacy SOP
• Execute Medication Delivery and Medication Cassette Exchange as per CHOP Pharmacy SOP
• Execute RIVA Batch Production as per CHOP Pharmacy SOP
• Pharmacy products are distributed accurately, with the appropriate quantity and at the time the product is needed during hourly medication delivery and Bin Exchange.
• Inventory Control
• Kanban Inventory system is adhered to 100% of time.
• Maintains and organizes inventory supply in a manner which minimizes inventory storage cost, wastage, and stock-outs. Ensures inventory is rotated properly, stored in appropriate conditions and location with 100% accuracy.
• Complete monthly medication expiration dating assignments in a timely manner. Identify and reorder expired medications inventory and ensures that stock is stored in accordance with manufacturer requirements.
• Assures the proper replacement of prescription drugs to stock upon requisitions from various departments of the hospital either manually or through the Pyxis System.
• Ensures the secure storage of narcotics and other controlled substances.
• Documents every transaction completely and accurately.
• No generation of discrepancies in the C2 Safe, Pyxis Medstation, or Inventory Logs.
• Ensures the destruction of returned controlled substance continuous medication infusions.
• Ensures secure storage of narcotics and other controlled substances on a regular basis. Maintains inventory records on narcotics and other forms of drugs as required by law.
• Performs inventory counts of controlled substances on safes as per policy and procedures.
• Achieve patient safety and satisfaction through the use of LEAN principles:
• 5S
• Elimination of Waste
• JIT
• Stand Work
• Quality
• Promotes and Complies with Standardized Procedures.
• Promotes and Complies with Standard Work.
• Identifies "waste" in ownership process and recommends solutions for implementation.