Baxter | 20Ways Summer Hospital 2024 Case Study

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CASE STUDY

www.baxter.com

IV workflow management systems that use

gravimetric analysis prevent users from creating

master formulation records for preparations

that are outside the system’s tolerance limits,

and if staff attempt to weigh a volume outside

the integrated scale’s tolerance limit the IV

workflow management system alerts the user.

IV workflow management systems document

all steps and components of the compounding

process (e.g., products used, the practitioner

who performed the compounding, the primary

engineering control, machine readable code scans,

date and time of preparation, alerts or warnings

presented during the process, the practitioner

who verified the preparation), and the information

is available to users in a log and/or report.

IV workflow management systems allow for

remote verification using video or image capture,

and, when used, gravimetric analysis.

IV workflow management systems track beyond-use

dating of opened or reconstituted products to warn

practitioners and prevent use of an expired product.

IV workflow management systems allow

for customization of labels (e.g., tall man

lettering, color print, reverse print, electronic

health record compatible barcode).

IV workflow management systems limit

the printing of the dispensing label until the

compounding process is complete.

Workload (e.g., incoming load) is documented

by the technology and captured in a report to

inform and facilitate operational improvement.

Close-call compounding events (e.g., wrong

drug scans) intercepted by the technology are

captured in a report to facilitate compounding

error analysis and process improvement.

Data in vendor reports are provided in a

useful format and do not require significant

manipulation by the end user.

When a system update is available, IV

workflow management system vendors

ensure all customers receive and install the

update in a reasonable timeframe.

2022 ISwMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology

A - Can be obtained from DoseEdge Technical Support

The use of IVWFM systems to help meet the Chapter <797>

standards is discussed far less, if at all. However, given the

broad functionality of some of these systems, such as the

DoseEdge system, they can influence pharmacy procedures and

documentation practices etc. which can directly or indirectly support

these requirements.

The following are many of the standards from the 2023 version of

USP <797> that could potentially be supported by using IVWFM

systems5.

USP Chapter <797> Standards

How DoseEdge

Functionality Could

Provide Support

3. PERSONAL HYGIENE AND GARBING

Personal hygiene and garbing are

essential to maintain microbial control of

the environment. Most microorganisms

detected in cleanrooms are transferred

from individuals. Squamous cells are

normally shed from the human body

at a rate of 106 or more per hour, and

those skin particles are covered with

microorganisms. Individuals entering a

compounding area must be properly garbed

and must maintain proper personal hygiene

to minimize the risk of contamination

to the environment and/or CSPs.

Individuals that may have a higher risk of

contaminating the CSP and the environment

(e.g., personnel with rashes, recent tattoos,

oozing sores, conjunctivitis, or active

respiratory infections) must report these

conditions to the designated person(s).

The designated person(s) is responsible for

evaluating whether these individuals should

be excluded from working in compounding

areas before their conditions have resolved

because of the risk of contaminating

the CSPs and the environment.

Remote verification

could help decrease

the number of

pharmacists required

to enter the cleanroom

to verify doses

including in-process

and final checks.

This can be especially

beneficial on off-shifts

when staffing may

be lower or when

pharmacist verifiers

with higher risks

for contamination

may be the only

pharmacist on duty.

4. FACILITIES AND

ENGINEERING CONTROLS

The design of the facility should

take into account the number of

personnel and their movements.

4.1 Protection from Airborne Contaminants

Proper design and controls are required

to minimize the risk of exposure of

CSPs to airborne contaminants.

Total airborne particle counts by ISO

classification must not be exceeded:

ISO 5 = 3520 particles/m3

ISO 7 = 352,000 particles/m3

Remote verification

can help minimize

the number of

pharmacist verifiers

needing to enter the

cleanroom which

may be able to affect

the overall design.

This decrease in

staff needing to enter

the cleanroom can

also be used as a

control mechanism

to decrease airborne

contaminants.

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