Compounded Sterile Preparations Continue to Harm or Kill Patients

Abstract

the US. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Recently, 17 babies were affected by improperly compounded heparin solutions in a Texas hospital and at least one baby died. 19 The question we have to ask ourselves as pharmacists and technicians is -why is this happening and what can be done to prevent it from recurring?Being a member of the USP's Council of the Experts, Sterile Compounding Committee, responsible for rewriting the sterile compounding chapter, I have realised that improving compounding practices and their outputs will not be the result of any one pharmacy standard, guideline, or regulation that has been or yet to be written. This is not to say that this USP chapter is not necessary or superfluous. It is a necessary document that provides health professionals who compound sterile medication, with minimum practice and quality standards based on evidence-based science and best practices. The next generation of any document needs to focus on 'bundles'. A bundle is a collection of specific practices and process steps grounded in solid science with the goal of improving outcomes. Dr Peter Provonost, critical care researcher at Johns Hopkins University, implemented a simple tool (bundle) -a checklist focused on catheter-related blood stream infections that used the Center for Disease Control's guidelines on hand hygiene as its cornerstone. In 2003, Michigan hospitals began implementing