SUMMER 2018 I HEALTH SYSTEM • INFUSION
WAY
Contents
Preceptor
Recognitions
Unit Dose
Done Right
Unit Dose
Done Right
Unit Dose,
Bar Coding,
Pharmacy &
Nursing Supply
Experts!
Unit Dose,
Bar Coding,
Pharmacy &
Nursing Supply
Experts!
• Ultraviolet Inhibitant
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• Reduces Cross Contamination
• Ideal for Meds Covered by USP 800
• Tamper-Evident
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• 1-D and 2-D Bar Coding
• Flexible Label and Report Formatting
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page 36-37
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page 39
Medi-Dose, Inc./
EPS, Inc. Delivers Bar
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page 41
Case Study:
Meeting Pharmacy
Compliance
and Regulatory
Challenges
Comprehensive Pharmacy
Services drives compliance
with an end-to-end process:
complete assessment,
strategy development,
and implementation.
SOLUTIONS & RESULTS:
Sterile Compounding (USP <797> and <800>)
SOLUTIONS: In January 2018, the Compliance and
Regulatory Services team provided a full assessment
of compounding safety practices from procurement
to administration in Dayton Children’s Hospital’s four
compounding locations that included review of:
•
Facility design
•
Workflow observations
•
Equipment and engineering controls
•
Environmental sampling
•
Cleaning and disinfection
•
Policy and procedures surrounding sterile
compounding
Following the assessment, the Compliance and Regulatory
Services team drafted a Compliance Report and developed
a plan for process improvement designed to optimize
safety, efficiency and effectiveness, and compliance.
At the request of the organization, due to a plethora of
ongoing projects on the current Director of Pharmacy’s
agenda, the Compliance and Regulatory Services team
offered a custom approach to managing the execution of
the project plan remotely. Currently an ongoing project,
the Compliance and Regulatory Services team is virtually
managing implementation and execution of the line items
in the plan, ensuring that timelines are met and freeing up
the Director of Pharmacy for other responsibilities.
RESULTS: As of March 2018, the project plan is approaching
25 percent completion. In February 2018, the Board of
Pharmacy surveyed one of the organization’s four sterile
compounding locations. Because some of the items identified
in the project plan were being acted upon, the surveyor issued
no further citations. At another location, guidance is currently
being provided for a full remodel of the sterile compounding
suite which includes working directly with the pharmacy team,
architects, engineers and facility administration.
THE CHALLENGE:
Achieving and sustaining compliance across the entire healthcare organization and lowering regulatory
risk while improving operational efficiency and effectiveness are critical goals for hospital and health
system pharmacies. When Dayton Children’s Hospital reached out to Comprehensive Pharmacy Services
(CPS) for support in assessing compliance and regulatory issues for controlled substances, sterile
compounding (USP <797> and <800>), The Joint Commission standards and 340B, CPS responded
with custom solutions from its Compliance and Regulatory Services and 340B teams.
CPS’ 340B team was able to take a good
340B program to a great 340B program and
IDENTIFIED $500,000
IN ADDITIONAL 340B OPPORTUNITIES
Meeting Pharmacy Compliance
and Regulatory Challenges
Comprehensive Pharmacy Services drives compliance with an end-to-end process:
complete assessment, strategy development and implementation.
CASE STUDY
page 42-45
WAY
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With one of the largest quality networks in the
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page 33
page 35
WAY
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