Reply To: Assistance in initiating a new sterile compounding service

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We are considering the initiation of a new pharmacy-led sterile compounding service at our hospital.

  1. If you have the budget, use it all ASAP or you will lose it.
  2. Build the Clean Room as per available resources. Make sure you have the right space for the available workload> be strategic so no extension/construction for next 20 years.
  3. Leave a space for future technologies i.e. Robots of the future, IV Workflow needs extra electric and network sockets, other compounding devices, etc.
  4. Make sure the contractor has healthcare experience and knows a bit about USP 797
  5. Horizontal LAFH ONLY for ordinary drugs (not vertical)

Due to limited resources at this time and as a first step, we narrowed down the types of medications to be prepared in a hood to antimicrobials (antibiotics, antivirals, and antifungals), nutrition (total parenteral nutrition, and pediatric electrolyte solutions), ophthalmic products, +/- monoclonal antibodies. We then determined the overall daily number of preparations requiring sterile compounding as well as the number of hours needed to complete those preparations.

  1. Good strategy, although I feel it is important to give priority for non-antimicrobial agents since these drugs protect themselves naturally. Just theoretical judgement.
  2. Work on standardization of doses then invest on batches- batches- batches

One of our main concerns is the fact that the current pharmacy operating hours are limited to 11 working hours on week days, 8 hours on Saturdays, and 3 hours on Sundays and holidays. This schedule, if maintained as such, prevents the pharmacy department from being able to cater for new orders requiring sterile compounding during pharmacy off-hours. The solution that we thought of would be to extend pharmacy operating hours to 24 hours.

  1. Great thoughts by Naveed & Nawal as shown in previous replies
  2. JCIA will mercy you if the nurses are well trained under pharmacy supervision in using aseptic technique (strict when needed especially in immunocompromised patients) when mixing/transferring parenteral drugs outside the duty hours.
  3. Make sure there is a dedicated mixing Bench at the nursing medication room and away from traffic and bed side… I don’t favour LAFW hood in nursing units.
  4. Have a pharmacist on call to answer nursing queries


Reply To: Assistance in initiating a new sterile compounding service
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