Leveraging a multidisciplinary oversight committee to ensure USP <797> and <800> compliance at a Veterans Affairs health system

Abstract

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Producing compounded sterile preparations (CSP) of the highest quality and ensuring safe hazardous drug handling are well-established priorities for pharmacy departments. Maintaining compliance with United States Pharmacopeia general chapters 797 and 800 (USP <797> and <800>) must also be a priority for health-system leadership. This report describes how a pharmacy-driven multidisciplinary committee was created to provide USP <797> and <800> oversight within a multicampus Veterans Affairs health system and the facility and safety outcomes achieved. Summary The Veterans Health Administration required facilities to establish an oversight committee to ensure USP-compliant CSP procedures and the safe handling of hazardous drugs in all aspects of the medication-use process. Spearheaded by the pharmacy department, the VA Palo Alto Health Care System (VAPAHCS) chartered the CSP Advisory Committee to achieve this goal. The membership was composed of department heads in the areas of pharmacy, nursing, environmental management services, engineering, facility planning, safety, industrial hygiene, employee health, supply chain services, infection control, and quality management and the health system’s director’s office. The medication safety officer served as the executive secretary for the advisory committee and was responsible for agenda development, minutes, and coordinating timely follow-ups on action items; the VAPAHCS deputy director served as chair. Monthly meetings were conducted to receive updates on targeted sterile compounding and hazardous drug handling objectives: environmental controls and monitoring, compliance with regulatory requirements, staff competency, hazardous drug exposure event analyses, and development of well-defined health-system policy to guide practice. Conclusion Taking a multidisciplinary approach to USP <797> and <800> compliance facilitated communications, created engagement, and ensured completion of action plans.

Canadian monitoring program of the surface contamination with 11 antineoplastic drugs in 124 centers

“…Wrzesniewski and Park specified that their oversight committee was responsible for supervising the development of training programs and tracking their completion. 25…”

“…24 Wrzesniewski and Park concluded that their multidisciplinary oversight committee "positively influenced" their compliance with USP 800 guidelines. 25 Their activities included tracking environmental monitoring reports and action plans. The 2021 ASSTSAS guide reiterated the necessity of having a hazardous drugs committee and the Quebec community of practice on the safe handling of hazardous drugs support this requirement.…”

“…Wrzesniewski and Park specified that their oversight committee was responsible for supervising the development of training programs and tracking their completion. 25 Respondents used a wide variety of training methods. Other groups have shown that oncology nurses significantly increased their knowledge and performance scores three months after attending a two-day workshop.…”