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ASHE 56th Annual Conference & Technical Exhibition


1102 - Managing Pharmacy Clean Rooms – A Multidisciplinary Approach


Jul 16, 2019 3:15pm ‐ Jul 16, 2019 4:15pm


Credits: None available.

Description

The Joint Commission (TJC) issued a letter in 2018 informing hospitals that due to recurring issues pertaining to the certification process for Pharmacy Sterile Compounding Clean rooms, this will be a focus of 2018-2019 TJC surveys. The Central Division of Atrium Health, with over 1,000 patient beds and 20 pharmacy clean rooms, was surveyed in 2018. We conducted a multidisciplinary review of requirements and roles and responsibilities around clean rooms and will provide you with a roadmap for developing a program for continual certification and share lessons learned from our TJC survey.

Learning Objectives:

  • Identify the pharmacy sterile compounding clean room environmental certification requirements per USP 797, USP 800, and CAG-003-2006 (Sterile Compounding Facilities).
  • Develop a roles and responsibility matrix and flow chart.
  • Define when certification is required, above and beyond every 6 months.
  • Provide requirements to the agency performing the certifications.

Speaker(s):

  • Dennis Ford, SASHE, CHFM, CHC, CHSP, CHEP, Director, Central Division Facilities Operations, Atrium Health
  • Mike Mango, Director of Pharmacy Services, Atrium Health
  • Tyler Greenwood, Manager, Pharmacy Operations, Atrium Health

Credits

Credits: None available.

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