Equipment and Components
Sterile Hazardous Compounding <800>

Purpose/ Applicability:  To provide guidelines for proper storage and cleaning of equipment and components within the hazardous side of the cleanroom.

Scope: Applies to all sterile hazardous compounding / preparations.

Definition(s): N/A

Equipment:

Beaker

Procedure:

Dedicated Equipment

• Compounding with hazardous drugs will only be performed with dedicated equipment, including but not limited to:
  • Beakers, graduated cylinders, other vessels
    • *Currently we only utilize a beaker within the HD room
• Each piece of equipment (that is reusable) used for HD compounding will be tagged or labeled in a manner that identified it as being dedicated to HD compounding
• Each piece of equipment that is not reusable, will be disposed of properly within the HD room
  • Dispose in the blue sharps bin if it is a syringe, vial, adaptor, or anything that may have come into contact with drug
  • Dispose in the trash can if it is plastic, paper, or any outer wrapping that has not come into contact with drug
• Any equipment utilized in the HD room must be sprayed down with alcohol before and after each use

Components

• Equipment / medications can be brought in or out through the pass through
• Brought in :
  • Item should be sprayed down with alcohol before being placed in the pass through as well as once it is pulled out of the pass through to ensure sterility
  • Item must also be sprayed down with alcohol again prior to being introduced into the hood
• Brought out :
  • Item from the hood (such as a medication) should be in a chemotherapy bag that is fully sealed prior to being placed in pass through
    • Item can be grabbed from anteroom side and brought out of cleanroom for use
  • Item from the negative pressure buffer room should be sprayed with alcohol prior to being placed in the pass through
    • If there is concern of chemotherapy contamination, item should be handled with non-sterile chemotherapy gloves while taking out of pass through into anteroom and out to where it needs to be handled
    • Do not handle items that have been exposed to chemotherapy without chemotherapy gloves